week 4 content Flashcards
Nursing care: ___________ c/s
- Position woman on table – wedge under right hip to prevent supine hypotension
- Support couple
- Instrument count – before, during, after
- Time out
- Document
- Time of Incision
- Time of Delivery of infant
- APGARS
- AROM
- Time of Placenta extracted
- EBL – estimated blood loss
- Meds received
during
Are these predictors of cervical insufficiency or Pre-Term Labor?
- shortened cervical length – less than 25 mm before term
- history of previous spontaneous abortion without contractions
Cervical insufficiency
Vacuum extraction or forceps?
- Suction cup placed on fetal occiput
- Pump is used to create suction
- Traction is applied
- Fetal head should descend with each contraction
Vacuum extraction
are these risks associated with CPD or macrosomia?
- dysfunctional labor
- uterine rupture
- perineal lacerations
- postpartum hemorrhage
- shoulder dystocia
macrosomia
what is this?
- thin tube with a balloon at the end
- used to induce labor
- inserted through the vagina and cervix into the lower part of the uterus.
- The balloon is then filled with sterile saline solution.
- The inflation of the balloon puts gentle pressure on the cervix, which can help it to soften and begin to open.
foley bulb
are these meds tocolytics or pitocin/oxytocin?
what do they do?
- Procardia (nifedipine)
- Magnesium sulfate
- Terbutaline (brethine)
- Progesterone therapy (Prometrium)
tocolytics
stop contractions
Are these advantages of combined spinal-epidural or spinal (regional anesthesia)?
- Onset – faster than just epidural
- Meds can be added to increase effectiveness
- Most drugs use low dose
combined spinal-epidural
if laboring mom with ROM has a fever, what will the nurse expect the FHR to be tachycardia or bradycardia?
tachycardia
Reassuring or Non-reassuring fetal status:
- Bradycardia
- Tachycardia
- Decreased fetal movement
- Meconium-stained amniotic fluid
- Persistent late decelerations
- accelerations
- Persistent severe variable decelerations
- moderate variability
- baseline between 110-160
N- Bradycardia
N- Tachycardia
N- Decreased fetal movement
N- Meconium-stained amniotic fluid
N- Persistent late decelerations
R- accelerations
N- Persistent severe variable decelerations
R - moderate variability
R - baseline between 110-160
T/F
what risks is the fetus/newborn exposed to when PROM or PPROM occurs?
- Respiratory distress
- Fetal sepsis
- asthma
- Malpresentation
- Prolapse of umbilical cord
- Non-reassuring FHR pattern
- itching
- Compression of the umbilical cord
- Premature birth
- Respiratory distress
- Fetal sepsis
F - asthma is not a risk associated with PROM/PPROM - Malpresentation
- Prolapse of umbilical cord
- Non-reassuring FHR pattern
F - itching is not a risk associated with PROM/PPROM - Compression of the umbilical cord
- Premature birth
which regional anesthesia is this describing - pudendal block or local analgesic?
Advantages
- Easy to admin
- No maternal hypotension risk
Disadvantage
- Urge to bear down may be decreased
pudendal block
If the patient is being induced/augmented with oxytocin and you notice a pattern of tachysystole followed by the onset of late decelerations, which UNCOIL would you implement first?
UNDO cause = you would first turn off the oxytocin because the cause was likely the lack of resting tone between contractions.
If not immediately resolved you would start implementing the other UNCOIL measures.
Painless dilation/thinning of cervix without contractions
Cervical insufficiency
“Incompetent cervix”
what is cricoid pressure is an intervention to prevent ___________ during placement of endotracheal tube, when the patient is under __________ anesthesia.
what is cricoid pressure is an intervention to prevent aspiration during placement of endotracheal tube, when the patient is under general anesthesia.
put the Stages of grief in order:
- depression
- denial
- anger
- acceptance
- bargain
Stages of grief
- denial
- anger
- bargain
- depression
- acceptance
4 types of ______________:
1. Foley bulb
2. Prostaglandin - Cytotec (misoprostol)
3. Prostaglandin - cervidil (dinoprostone)
4. Stripping of membranes
Cervical ripening
Nursing care: ______ c/s (before , during, after)
- Assist with epidural or spinal
- Admin ordered meds to neutralize stomach acid – Pepcid, reglan, bicitra
- Monitor maternal vitals under anesthesia
- Monitor FHR with doppler or internal lead (FSE)
- Insert foley catheter
- Prepare abdomen and perineum – shave
- Make sure all necessary staff and equipment are present
before
match term to definition:
Regional anesthesia, Systemic analgesia, general anesthesia
IV pain med management
Temporary and reversible loss of sensation
puts you in an unconscious state, eliminating awareness of pain and sensation
Systemic analgesia
IV pain med management
Regional anesthesia
Temporary and reversible loss of sensation
general anesthesia
puts you in an unconscious state, eliminating awareness of pain and sensation
what is this? Episiotomy or Amniotomy
OB or nurse mid wife causes AROM by using hook to create a small tear in the amniotic membrane which allows fluid to escape
Amniotomy
foley bulb:
risks
- uterine hypo/hyper stimulation?
- non-reassuring/reassuring fetal status?
- higher/lower rate of postpartum hemorrhage?
- uterine rupture/atony?
risks
- uterine hyperstimulation
- non-reassuring fetal status
- higher rate of postpartum hemorrhage
- uterine rupture
T/F about systemic analgesia admin
- All systemic meds used for pain relief during labor cross the placental barrier
- Fetal liver and kidney excretion is adequate for metabolizing meds
true - All systemic meds used for pain relief during labor cross the placental barrier
False - Fetal liver and kidney excretion is inadequate for metabolizing meds
which ones help speed up labor?
- cerclage
- amniotomy
- foley bulb
- prostaglandins
- tocolytics
- stripping of membranes
- pitocin
- epidural
speed up labor:
- amniotomy
- foley bulb
- prostaglandins
- stripping of membranes
- pitocin
rationale:
- cerclage - sutures on the cervix
- tocolytics - stop contractions
- epidural - for pain, may actually slow labor
Cervical ripening
Performed before/after induction
Cervical ripening
Performed before induction, helps speed it up
nursing care:
Pt c/o sudden onset of large gush of blood and painful abdomen.
FHR is reassuring.
suspect _________?
Next step?
- Suspect abruptio placentae
- Palpate abdomen for firmness
placental abruption or placenta previa
_____________ = placenta detachment
______________ = placenta over cervix
placenta previa = placenta over cervix
placental abruption = placenta detachment
placental abruption or placenta previa?
painful
placental abruption
Nursing care: after epidural or spinal placement
T/F
- Monitor maternal and fetal vitals
- Assess for hypotension and intervene if necessary (UNCOIL)
- Admin antiemetics as ordered
- Monitor RR
- Assess bladder and catheterize if unable to void
- Assess for difficulty breathing, ringing in ears, funny taste in mouth
- lower HOB
T - Monitor maternal and fetal vitals
T - Assess for hypotension and intervene if necessary
T - Admin antiemetics
T - Monitor RR
T - Assess bladder and catheterize if unable to void
T - Assess for difficulty breathing, ringing in ears, funny taste in mouth
F - Keep HOB raised!! – gravity makes anesthesia go to abdomen and back area
VBAC or TOLAC?
considered __________ until successful vaginal birth after c/s
considered ___________ once successful vaginal birth after c/s has been achieved
TOLAC - Pt considered TOLAC (trial of labor after cesarean) until successful
VBAC - Vaginal birth after c/s
T/F - Naloxone (Narcan) reverses mild respiratory depression of opiates/opioids on mom and fetus
T/F - Naloxone (Narcan) can cause withdrawal and Neonatal Abstinence Syndrome (NAS) if mother has Substance Use Disorder (SUD) so it is contraindicated for these patients
True
True
Are these disadvantages of epidural or spinal (regional anesthesia)?
- Maternal hypotension
- Urinary retention
- Itching
- May slow down labor and contractions – can add pit
- Post delivery back pain
- Meningitis
- Cardio respiratory arrest
- Vertigo
- Onset – up to 30 mins
epidural
with a foley bulb - the inflated balloon puts gentle pressure on the cervix, which can help it to ______ and ________
soften and begin to open
Hydramnios/polyhydramnios or Oligohydramnios:
________________
- preterm labor risk
- amniocentesis
__________________
- monitor fetus for risks
- renal and urinary malformations
- fetal skin and skeletal abnormalities
- pulmonary hypoplasia – underdeveloped lungs
- cord compression
Hydramnios/polyhydramnios = 2000 mL+
- preterm labor risk
- may need to removal excess fluid – amniocentesis
Oligohydramnios = less than 500 mL
- monitor fetus for risks
- renal and urinary malformations
- fetal skin and skeletal abnormalities
- pulmonary hypoplasia – underdeveloped lungs
- cord compression
T/F
Possible causes of PROM/PPROM
- UTI
- Previous history of PPROM
- Oligohydramnios
- Multiple pregnancies
T - any infection
T - Previous history of PPROM
F - Hydramnios
T - Multiple pregnancies
are these risks associated with multiple gestation or AMA?
- preterm labor
- uterine dysfunction
- abnormal fetal presentations
- instrumental or c/s birth
- postpartum hemorrhage
- higher mortality rate than for single fetus
- decreased intrauterine growth rate
- increased incidence of fetal anomalies
- increased cord accidents
- increase in Cerebral Palsy
multiple gestation
T/F about systemic analgesia admin
admin when:
- mom is uncomfortable
- there is a well established labor pattern
- contractions are occurring irregularly
- there is a significant duration of contractions
- contractions are mild intensity
Admin systemic analgesia when:
T - when mom is uncomfortable
T - well established labor pattern
F - contractions must be occurring regularly
T - significant duration of contractions
F - contractions must be moderate to strong intensity
what would the nurse suspect with these s/s
- sudden onset
- chest pain
- dyspnea
- cyanosis
- frothy sputum
- tachycardia
- hypotension
- massive hemorrhage
Amniotic fluid embolism
(Anaphylactoid syndrome)
T/F
nursing care: macrosomia
- identify macrosomia before labor begins
- evaluate maternal pelvis
- estimate fetal size by US
- consider c/s
- lack of fetal descent may indicate too large for vaginal birth
- risk for unexpected shoulder dystocia
- nurse may need to get woman into mcroberts maneuver or apply suprapubic pressure to help deliver shoulder dystocia baby
- apply fundal pressure
- identify macrosomia before labor begins
- evaluate maternal pelvis
- estimate fetal size by US
- consider c/s
- lack of fetal descent may indicate too large for vaginal birth
- risk for unexpected shoulder dystocia
- nurse may need to get woman into mcroberts maneuver or apply suprapubic pressure to help deliver shoulder dystocia baby
F - NEVER apply fundal pressure
what is this?
the umbilical cord slips down into the vagina ahead of the baby during labor or delivery, it is compressed against mom’s pelvis and oxygen supply to fetus is cut off
Umbilical cord prolapse
what is the nurse concerned with when giving pt systemic analgesia (opioids and opiates)?
maternal s/e
- Drowsiness?
- Dizzy?
- Fainting?
- anemia?
- Hypotension or hypertension?
- Respiratory depression?
- Constipation or diarrhea?
- fever?
- Itching?
- is a history of substance abuse a concern?
- n/v?
neonatal s/e
- Respiratory depression?
- Neurobehavioral depression?
- Respiratory acidosis?
maternal s/e
- Drowsiness
- Dizzy
- Fainting
- Hypotension
- Respiratory depression
- Constipation
- Itching
- is a history of substance abuse a concern - YES
- n/v
neonatal s/e
- Respiratory depression
- Neurobehavioral depression
- Respiratory acidosis
Fetal risk associated with PTL or post term pregnancy?
- Decreased perfusion
- Oligohydramnios
- Small for gestational age (SGA)
- Macrosomia – big for gestational age
- Increased risk for meconium-stained fluid
- Risk for meconium aspiration syndrome
Post term pregnancy
- Decreased perfusion as placenta gets older
cesarean birth
what are the 2 Skin incisions?
what are the 3 uterine incisions?
transverse, low transverse, classical, low vertical, vertical
Skin incision:
- Transverse incision – horizontal, Pfannenstial “bikini”
- Vertical incision
Uterine incision:
- Low transverse incision – horizontal
- Classical incision – vertical, mid belly
- Low vertical incision – vertical, low belly
amnioinfusion
Purpose:
- Replace _____________
- repetitive __________ decels with increasing intensity
- Meconium _____________
- Replace amniotic fluid
- repetitive variable decels with increasing intensity
- Meconium dilution
which bishop score is best?
2/13
5/13
7/13
10/13
higher score = higher likelihood of vaginal birth
8+/13 is ideal
Forceps assisted birth:
Forceps used to
- guide baby out with push of contractions
or
- pull baby out bc mom’s too exhausted to push
Forceps assisted birth
Forceps used to guide baby out with push of contractions, not pull baby out
which intrapartum complication would we expect to treat with:
- serial cervical US assessments
- bed rest
- progesterone (tocolytic)
- antibiotics
- cerclage
- monitor cervical length
- transvaginal US starting 16-24 weeks gestation
- teach warning signs of impending birth
cervical insufficiency, PPROM/PROM, or PTL?
Cervical insufficiency - Painless dilation/thinning of cervix without contractions
progesterone - Helps sustain pregnancy
Nursing care: Pts BP drops after admin of regional anesthesia (epidural), also some FHR late decelerations are noted
what should the nurse do?
- give oxygen
- reposition
- oxytocin
- ephedrine
- stop IV fluid bolus
- lower HOB
- UNCOIL!!!
- give Oxygen
- Turn/reposition
- stop pitocin/oxytocin
- give Ephedrine – vasoconstrictor
- give IV fluid bolus
- Lower HOB
prostaglandins
cytotec (miso) or cervidil (dino)?
-route – vaginal
-purpose – stimulate contractions to thin cervix
-can remove by pulling string (like tampon)
-bedrest for 2 hours after dose, then pt can be up to bathroom
-pat dry after voiding, don’t wipe to avoid pulling it out of place
cervidil (dino)
2 types of episiotomy incisions
-Midline –
-Mediolateral –
- Midline – straight line down from vagina to anus
- Mediolateral – diagonal incision from vagina out towards leg
T/F
Nursing care: placenta previa
- SVE
- Assess for bleeding – may need transfusion
- Assess mom vitals
- Assess fetal status
- FHR- internal monitor
- External toco for contraction monitoring
- Anticipate unengaged fetal presenting part
- Transverse lie is common
- Get consents for c/s
- Admin tocolytics (magnesium sulfate, Procardia, terbutaline)
F - No SVE!! For confirmed and suspected – even if there is the slightest chance of a previa nothing in the vagina, no exam
- Assess for bleeding – may need transfusion
- Assess mom vitals
- Assess fetal status
F - FHR- external monitor
- External toco for contraction monitoring
- Anticipate unengaged fetal presenting part
- Transverse lie is common
- Get consents for c/s
- Admin tocolytics (magnesium sulfate, Procardia, terbutaline) – meds that stop contractions
placental abruption or placenta previa?
- Placenta is in the right spot, but it is separating/ripping away from uterine wall prematurely
there is less perfusion and oxygen getting to fetus since the placenta is losing connection to uterus - Instead of placenta being at the top of the uterus, it is at the bottom covering the cervix opening
- as the uterus contracts and dilates at the bottom where the cervix is, the placenta is less and less connected to uterine wall
- bright red, painless bleeding occurs
- abruptio placentae
- placenta previa
nursing care: hypertonic/tachysystole contractions or hypotonic contractions?
- assess contractions, vitals, and FHR
- provide comfort and support – back rubs
- change positions
- turn of oxytocin
- tocolytics
- sedation or pain meds
nursing care: hypertonic/tachysystole contractions
- assess contractions, vitals, and FHR
- provide comfort and support – back rubs
- change positions
- turn of oxytocin
- tocolytics – stop contractions
- sedation or pain meds
what is this?
baby’s head is too large or the mother’s pelvis is too small to allow for a vaginal delivery.
Deliver c/s
CPD
Cephalopelvic disproportion
Nursing care: before or after epidural or spinal placement?
- Assess maternal and fetal status
- Assess labor process
- Start IV and admin warmed LR
- Help woman into position for placement
before placement
which 2 regional anesthesia are usually used in 2nd stage of labor or laceration/episiotomy repair?
epidural, spinal, combined epidural-spinal, pudendal block, or local analgesic?
pudendal block
local analgesic
which meds STOP contractions?
pitocin/oxytocin or tocolytics?
tocolytics
which are examples of labor augmentation?
- Pitocin
- amniotomy
- Stripping membranes
- Ambulation
all
The pt is:
8 cm/100%/0
c/o 10/10 pain
begging for IV pain meds/opioids/systemic analgesia
Should the nurse give the ordered dose of IV pain meds/opioids/systemic analgesia - why or why not?
No, do not give IV pain meds/opioids/systemic analgesia if delivery is close bc it causes neonatal respiratory depression and we don’t want the newborns respiratory system to be depressed when born
8 cm/100%/0 = Delivery in immediate future = contraindication
Nursing care for amniotomy
- Check ________ (#1 nursing priority after water breaks)
- C –
- O –
- A –
- T -
- Maternal temp Q ___ hours
- Check FHR (#1 nursing priority after water breaks)
- C – fluid color, clear, bloody, meconium
- O – foul odor or odorless
- A – amount, scant, moderate, copious
- T - Date and time of AROM
- Maternal temp Q2 hours
are these complications associated with general anesthesia or regional anesthesia?
- fetal respiratory depression
- maternal intubation
- aspiration!!
- Higher risk of Postpartum hemorrhage
- Less feeling of control
- Not awake during labor and birth
- Support person may not be present
- Maternal amnesia – doesn’t remember labor and birth
general anesthesia
Premature rupture of membranes (PROM) or Preterm premature rupture of membranes (PPROM) :
- water breaks before the onset of labor (no contractions)
- less than 37 weeks
Preterm premature rupture of membranes (PPROM) :
T/F about systemic analgesia admin
True = ok
false = not ok
fetal assessments include:
- FHR 110-160 bpm
- Non-reactive non-stress test
- Minimal variability
- Delivery is soon and mom is in a lot of pain
- reassuring FHR pattern
- if FHR shows decreased variability after admin - red flag
fetal assessments include:
T - FHR 110-160 bpm
F - must have a Reactive non-stress test before admin
F - must have Moderate variability before admin
F - Delivery must not be in immediate future – do not give if delivery is close bc it causes neonatal respiratory depression and we don’t want the newborns respiratory system to be depressed when born
T - Must have reassuring FHR pattern in order to give systemic analgesia
F - After admin FHR may show decreased variability
which one is the main risk with a VBAC?
- Ecchymosis, edema, along the face
- Increased risk for hemorrhage
- Uterine rupture where c/s scar is
- uterine hyperstimulation
- Uterine rupture where c/s scar is
- high gravidity
- increasing age
- AMA
- Prior c/s
- Recent spontaneous or induced abortion
- Cigarette smoking
- More common with male fetus
cause placental abruption or placenta previa?
placenta previa
Malposition, Malpresentation, position, Presentation
_____________ - position of the fetal head in relation to the mother’s pelvis (OA is desired)
______________ – baby is in occiput-posterior (OP) position
______________ – which fetal body part is coming through the birth canal first (head/occiput is desired)
________________ - a fetal body part other than the head is positioned to enter the birth canal first. (shoulder, brow, breech (3), face)
position - position of the fetal head in relation to the mother’s pelvis (OA is desired)
Malposition – baby is in occiput-posterior (OP) position
Presentation – which fetal body part is coming through the birth canal first (head/occiput is desired)
Malpresentation - a fetal body part other than the head is positioned to enter the birth canal first. (shoulder, brow, breech (3), face)
Possible causes of PROM/PPROM
- healthy cervix
- History of lase conization or LEEP procedure
- Bleeding during pregnancy
- Maternal genital tract anomalies
F - Incompetent cervix is a cause of PROM/PPROM
all true
- History of lase conization or LEEP procedure
- Bleeding during pregnancy
- Maternal genital tract anomalies
foley bulb:
Advantages
-Cervical effacement speeds up/slows down?
-Shorter/longer labor?
-Higher/Lower requirements for oxytocin during labor induction?
-Vaginal birth is achieved within 24/48 hours for most women?
-c/s birth is increased/reduced?
advantages
- Cervical effacement speeds up
- Shorter labor
- Lower requirements for oxytocin during labor induction
- Vaginal birth is achieved within 24 hours for most women
- c/s birth is reduced
Preterm labor (PTL)/premature onset of labor (POL) – labor that occurs between _____ - _____ weeks
Preterm labor (PTL)/premature onset of labor (POL) – labor that occurs between 20-36 weeks
are these indications or contraindications for a VBAC?
- History of c/s birth a low transverse uterine incision
- Adequate pelvis
- No other uterine scars or previous uterine rupture
- No history of myomectomy
- Available physician who is able to do c/s if necessary
- In house anesthesia personnel if necessary
indications
Nursing care: shoulder dystocia
- Lower or elevate HOB?
- Mcroberts or Leopolds maneuver? – supine, rotate legs up and out, bring knees to chest
- Suprapubic or fundal pressure? – downward with hand
- Document interventions and length of time dystocia?
- Lower HOB
- Mcroberts maneuver – supine, rotate legs up and out, bring knees to chest
- Suprapubic pressure – downward with hand
- Document interventions and length of time dystocia
Nursing care for amniotic fluid embolism or cervical insufficiency?
- stabilize cardiovascular system
- stabilize respiratory system
- displace uterus during CPR
- blood infusion
- central venous pressure line (CVP) – monitors for fluid overload
- immediate birth may be needed
amniotic fluid embolism
Neonatal or maternal risks for using forceps:
- Ecchymosis, edema, along the face
- Caput succedaneum or cephalhematoma
- Transient facial paralysis, brachial plexus
- Cerebral hemorrhage
- Clavicle fractures
- High neonatal bilirubin levels
neonatal risks
Nursing care: promote cardiac function during labor in Pt with heart disorder
- Side lying position or supine position?
- lower or elevate HOB?
- Side lying position
- HOB elevated
episiotomy or amniostomy?
Surgical incision of the perineum to enlarge the vaginal outlet
episiotomy
Cytotec (misoprostol) and cervidil (dinoprostone):
these 2 meds are prostaglandins or tocolytics?
used to speed up or slow down labor?
prostaglandins
stimulate contractions, thin cervix, and speed up labor
Maternal or neonatal risks for using forceps:
- Vaginal and cervical lacerations
- Periurethral lacerations
- Extension of a median episiotomy in to the anus
- Anal sphincter injury
- Perineal edema
maternal risks
these are Risk factors for placenta adherence or retained placenta?
- Placenta previa
- History of uterine surgery
- Endometrial defects
- AMA
- Parity - number of times a woman has delivered a baby past 24 weeks gestation
- c/s birth indicated
placenta adherence - abnormal adherence of the placenta to the uterine wall (accreta, increata, percreta)
Grade/severity of placenta abruption:
- Grade ____ – mild separation, mild bleed
- Grade ____ – partial separation, moderate bleed
- Grade ____ – complete separation, moderate-severe bleed
Grade/severity
- Grade 1 – mild separation, mild bleed
- Grade 2 – partial separation, moderate bleed
- Grade 3 – complete separation, moderate-severe bleed
cytotec (miso) or cervidil (dino)
-route – vaginal
-purpose – stimulate contractions to thin cervix, may also be given after delivery to help with bleeding
-cant remove/undo bc it is absorbed by body
-do not start pitocin induction within 4 hours of last dose
cytotec (miso)
_____________ – pregnancy has gone longer than the estimated date of birth at 40 weeks (EDB)
______________ – pregnancy has gone longer than 42 weeks
Post term, Post dates
Post dates – pregnancy has gone longer than the estimated date of birth at 40 weeks (EDB)
Post term – pregnancy has gone longer than 42 weeks
what is this? bishop score or podalic score
prelabor status evaluation scoring system for induced labor pts
looks at
- Dilation
- Effacement
- Station
- Cervical consistency – firm, moderate, soft
- Cervical position
tells how likely are you to deliver vaginally
higher score = higher likelihood
8+/13 is ideal
bishop score
2 types of Version (ways to turn the fetus in utero):
__________________
- external manipulation of maternal abdomen to change fetus breech to cephalic position
__________________
- Internally changing fetus position from breech to cephalic
- Used in delivery of 2nd twin
- Less common
External cephalic version (ECV), Podalic version (internal)
-External cephalic version (ECV)
- external manipulation of maternal abdomen to change fetus breech to cephalic position
-Podalic version (internal)
- Internally changing fetus position from breech to cephalic
- Used in delivery of 2nd twin
- Less common
what is this? Lacerations, retained placenta, placental adherence
abnormal adherence of the placenta to the uterine wall
Associated with
- maternal hemorrhage-
- failed placental separation after birth
- High rate of abdominal hysterectomy
placental adherence
are these reasons for using forceps or c/s birth:
- Heart disease
- Acute pulmonary edema or pulmonary compromise
- Intrapartum infection
- Prolonged second stage
- Exhaustion
- Non-reassuring fetal strip
Forceps assisted birth
nursing care: Umbilical cord prolapse
- _________________ #1 – recognize if the fetus presenting part is high in pelvis and ROM = bed rest
- If cord noted during SVE – _________________
- Position for gravity to help relieve compression – knee chest or Trendelenburg
- Oxygen mask
- Prepare for c/s
nursing care : Umbilical cord prolapse
- Prevention #1 – if fetus presenting part is high in pelvis and ROM = bed rest
- If cord noted in SVE – keep gloved fingers in vagina to relieve pressure off cord
- Position for gravity to help relieve compression – knee chest or Trendelenburg
- Oxygen mask
- Prepare for c/s
match tocolytic to drug facts
Procardia (nifedipine), Progesterone therapy (Prometrium), Magnesium sulfate, Terbutaline (brethine)
_______________
- Monitor BP
_________________
- Bolus IV, then maintenance
- Monitor LOC, RR, BP, reflexes and I&O
_________________
- Don’t give if HR >120
- Teach s/e – heart racing and feeling jittery
- Monitor HR
___________________
- Helps sustain pregnancy
- suppository
- Procardia (nifedipine)
PO
Monitor BP
——- - Magnesium sulfate
Bolus IV, then maintenance
Monitor LOC, RR, BP, reflexes and I&O
relaxes muscles
———- - Terbutaline (brethine)
SQ
Don’t give if HR >120
Teach s/e – heart racing and feeling jittery
Monitor HR
———- - Progesterone therapy (Prometrium)
Helps sustain pregnancy
suppository
are these risks associated with CPD or shoulder dystocia?
- Brain damage from hypoxia
- Brachia plexus damage
- Umbilical cord occlusion
Shoulder dystocia
Hypertonic contractions (tachysystole) = more than ___ contractions in ___ mins
Hypotonic contractions = less than ___ or ___ contractions in ___ mins
- low intensity contractions
Hypertonic contractions (tachysystole) = more than 5 contractions in 10 mins
Hypotonic contractions = less than 2 or 3 contractions in 10 mins
- low intensity contractions
Types of placental adherence: Increta, Percreta, Accreta
- _________ – placenta attaches to myometrium
- __________ – placenta invades myometrium
- __________ – placenta penetrates myometrium and beyond (nearby organs, bladder, bowel, etc.)
Types
- Accreta – placenta attaches to myometrium
- Increta – placenta invades myometrium
- Percreta – placenta penetrates myometrium and beyond (nearby organs, bladder, bowel, etc.)
Fetal shoulder stick behind pelvis/suprapubic bone
Shoulder dystocia
which meds STOP labor or CONTINUE labor:
- Procardia (nifedipine)
- Pitocin/oxytocin
- Magnesium sulfate
- Terbutaline (brethine)
- cervidil (dinoprostone)
- Progesterone therapy (Prometrium)
- Cytotec (misoprostol)
S - Procardia (nifedipine)
C - Pitocin/oxytocin
S - Magnesium sulfate
S - Terbutaline (brethine)
C - cervidil (dinoprostone)
S - Progesterone therapy (Prometrium)
C - Cytotec (misoprostol)
Maternal risk associated with PTL or post term pregnancy?
- Perineal damage
- Hemorrhage
- Increased risk of c/s birth
- Anxiety
- Emotional fatigue
- Persistence of normal discomforts
Post term pregnancy
which of these would be appropriate Nursing care options for non-reassuring fetal status:
- Recognize patterns
- Change positions
- Correct Hypotension
- give oxytocin
- stop tocolytics
- IV fluids
- SVE
- If not correctable – immediate birth
Nursing care
- Recognize patterns
- Change positions
- Correct Hypotension
- Stop oxytocin - idea is to stop contractions b/c baby is not doing well with them
- Give tocolytics - idea is to stop contractions b/c baby is not doing well with them
- IV fluids
- SVE
- If not correctable – immediate birth
macrosomia
Large fetus = greater than ___________ g (8 lbs and 13 oz)
4000 g
Are these disadvantages of combined spinal-epidural or spinal (regional anesthesia)?
- Higher chance of nausea
- Pruritus
combined spinal-epidural
Nursing care:
Pt is being induced with oxytocin and FHR increases to 175 BPM with absent variability
what should nurse do?
- UNCOIL
- Turn oxytocin off
What type of FHR patterns would be likely seen in a pt who is actively having abruptio placentae:
reassuring or non-reassuring patterns?
- Any non-reassuring patterns
nursing care for placenta adherence or retained placenta?
- watch for bleeding prior to delivery
- deliver before 38 weeks
- type and cross for blood transfusion
- many women have abdominal hysterectomy to prevent hemorrhage
- surgery – repair damage organs
placenta adherence
Nursing care: amnioinfusion
- Frequently check pads to make sure _____________
- ___________ amount of clear fluid on pad every hour is a normal finding
- Frequently check ____________ and MVUs
- if MVUs are elevated, what should you do?
Nursing care
- Frequently check pads to make sure fluid is being returned
- Moderate amount of clear fluid on pad every hour is a normal finding
- Frequently check resting tone and MVUs
- if elevated turn off amnioinfusion
Amnioinfusion or amniotomy?
Warmed sterile NS or LR is placed into uterus via IUPC
Amnioinfusion
Are these disadvantages of epidural or spinal (regional anesthesia)?
- Higher rate of Hypotension – nurse may bolus fluid to prevent hypotension
- Higher risk for fetal hypoxia
- Short acting
spinal
what is this? Lacerations, retained placenta, placental adherence
retention of placenta beyond 30 mins after birth
- Excessive bleeding
- May require manual removal
- May require blood transfusion
- Infection
- Subinvolution - uterus doesnt shrink back to normal size
retained placenta
- Maternal HTN
- Domestic violence
- Trauma
- Fibroids
- Uterine over distension
- FGR
- Male fetus more common
- Elevated alpha fetoprotein
- Alcohol
- Cigarette
- Cocaine
- Short umbilical cord
- High parity
- AMA
causes placental abruption or placenta previa?
placental abruption
Nursing care: ________ c/s (before, during, after)
- Normal newborn post delivery care
- Monitor vitals Q15 min
- Check surgical dressing
- Palpate fundus and check lochia
- Monitor I&O
- Admin meds as ordered – oxytocin and pain meds
after
Multiple gestation -
having 3 kids at 3 different times or having twins, triplets, etc.
Twins, triplets, etc.
If the patient just received an epidural and you notice her blood pressure is dropping and the onset of FHR decelerations, which UNCOIL would you implement first?
UNDO cause = you would first bolus IV fluids because the cause is likely the hypotension following regional anesthesia.
If not immediately resolved you would start implementing the other UNCOIL measures.
Types of placenta previa
___________ – placenta is completely covering cervix opening
- c/s
____________– placenta is partially covering cervix opening
- c/s
____________ – placenta is within 2 cm of covering cervix opening
- Vaginal birth – high risk
- c/s
______________ – placenta is not at the top of the uterus, not at the bottom either
- Vaginal birth – ok
Partial, Marginal, Complete, Low lying
Types
Complete – placenta is completely covering cervix opening
- c/s
Partial – placenta is partially covering cervix opening
- c/s
Marginal – placenta is within 2 cm of covering cervix opening
- Vaginal birth – high risk
- c/s
Low lying – placenta is not at the top of the uterus, not at the bottom either
- Vaginal birth – ok
Nursing care for placenta previa or placenta abruption?
- External monitor of contractions and fetus
- c/o abdominal pain
- abdominal girth
- development of DIC via coagulation tests
- priorities – maintain maternal cardiovascular status bc of blood loss
- c/s is often safest option
placenta abruption
Are these advantages of epidural or spinal (regional anesthesia)?
- Onset - Immediate
- Relatively easy admin
- Smaller drug volume
spinal
are these indications or contraindications for c/s birth?
- Complete placenta previa
- CPD
- Placental abruption
- Active genital herpes
- Umbilical cord prolapse
- Failure to progress in labor
- Tumors that obstruct birth canal
- Breech
- Previous c/s
- Major congenital anomalies
- Non-reassuring fetal status
Cesarean birth
Indications
what is the first thing the nurse should do after pt water breaks from amniotomy?
check FHR
Nursing considerations: pitocin
- Need reactive NST before starting pitocin?
- Need SVE?
- Need bishop score?
- Can/can’t be used with foley bulb?
- requires Continuous fetal monitoring?
- Titrate – increase/decrease 1-2 mu/min Q 30 mins? - volutrol required?
- Can/can’t use at any stage of labor?
Nursing considerations
- Need reactive NST before starting pit
- Need SVE with bishop score
- Can be used with foley bulb
- Continuous fetal monitoring
- Titrate – increase 1-2 mu/min Q 30 mins (volutrol required)
- Can use at any stage of labor
Butorphanol tartrate (stadol)
Nalbuphine hydrochloride (nubain)
Meperidine (Demerol)
Fentanyl (sublimaze)
Naloxone (Narcan)
are examples of:
Regional anesthesia, Systemic analgesia, general anesthesia
Systemic analgesia
IV pain med management
is amniotomy labor induction or augmentation?
Would an amniotomy be performed to gain access to fetus or uterus for internal monitor, such as to place a FSE or IUPC?
BOTH
yes
Amniotomy - OB or nurse mid wife causes AROM by using amnihook to create a small tear in the amniotic membrane which allows fluid to escape
Type of placenta abruption:
___________
- the edge of the placenta is separating
Bleeding is apparent
_______________
- The middle of the placenta is separating, the edges are still connected
- Bleeding is concealed
_____________
- The entire placenta is separated
- Bleeding may be concealed or apparent massive vaginal bleed
Complete, Marginal, Central
Type
Marginal
- the edge of the placenta is separating
- Bleeding is apparent
Central
- The middle of the placenta is separating, the edges are still connected
- Bleeding is concealed
Complete
- The entire placenta is separated
- Bleeding may be concealed or apparent massive vaginal bleed
Normal amniotic fluid = ________ mL
Hydramnios/polyhydramnios = __________ mL+
Oligohydramnios = less than ________ mL
normal AFI (amniotic fluid index) = _______ cm
Normal amniotic fluid = 600-1000 mL
Hydramnios/polyhydramnios = 2000 mL+
Oligohydramnios = less than 500 mL
normal AFI (amniotic fluid index) = 5-25 cm
nursing care: forceps
- Document length of time forceps were used – when _________ and when __________
- Assess for complications after delivery – such as vaginal ____________
- Document length of time forceps were used – when applied and when removed
- Assess for complications after delivery – such as vaginal lacerations
A 27 week gestation patient calls the nurse complaining of:
- uterine contractions – at least 4 Q 20 mins or 8 Q 1 hr
- cervical change or dilation
- mild cramps in lower abdomen
- constant or intermittent pelvic pressure
- gush of clear fluid from vagina (ROM)
- Constant or intermittent dull pain in lower back
- Increased vaginal discharge
what does the nurse suspect is happening?
LABOR
Preterm labor (PTL) or premature onset of labor (POL) because she is between 20-36 weeks
T/F
Side lying with lower extremities elevated is best position for multiple gestation patients complaining of DOE and back pain?
true
what is this?
OB, nurse mid wife, NP gently sweeps their finger between the amniotic sac and the wall of the uterus - Separates the amniotic membranes from the lower uterine segment
- This may cause the release of prostaglandins, which help ripen the cervix and stimulate contractions.
Stripping of membranes
_____________ is used only for:
- emergent deliveries
- low platelet count requiring c/s delivery
- scheduled c/s and unable to place spinal
systemic analgesia, regional anesthesia, general anesthesia?
general anesthesia
A pt comes in with PPROM
ordered meds include betamethasone (selestone) or dexamethasone
the nurse knows this is one of the priority medications to give
what is this med?
why is it important to give before the delivery of the baby?
If possible, how many hours should we delay delivery after first dose?
corticosteroid
since this baby is preterm it is important to give it steroids to enhance fetal lung maturity before it is delivered (this is why it is priority)
48 hours
which one is indicated and contraindications for VBAC?
- History of c/s birth with a low transverse uterine incision
- History of c/s birth with a vertical uterine incision
c/s indicated - History of c/s birth a low transverse uterine incision
c/s contraindicated - History of c/s birth a vertical uterine incisions)
what is this? Lacerations, retained placenta, placental adherence
spontaneous tearing of the perineal area
- Bright red vaginal bleeding persists despite well contracted uterus
- 1st – 4th degree lacerations
- Assist with repairs during 4th stage of labor
- Observe for bleeding during postpartum period
Lacerations
T/F about systemic analgesia admin
True = ok
False = not ok
maternal assessments include:
- mom is willing to receive meds according to birth plan
- vitals are stable, but BP is a little high
- no allergies
- no hypotension
- some non-reassuring fetal strip patterns
- document med, dose, route
- keep all side rails raised
- requires assist to bathroom
- bloody show on pad is a red flag
maternal assessments
T - mom is willing to receive meds
T - vitals are stable, its ok if BP is a little high (b/c opioids will lower it)
- no contraindications –
T - allergies
T - hypotension
F - fetal strip pattern must be reassuring to admin systemic analgesia!!
T - document med, dose, route
F - only keep upper side rails raised!!
T - requires assist to bathroom
F - bloody show on pad is normal and expected
Are these advantages of epidural or spinal (regional anesthesia)?
- Produces good analgesia – complete pain relief in abdomen and back
- Woman can remain fully awake during labor and birth
- Continuous technique allows different blocking for each stage of labor
- Dose can be adjusted
epidural
when starting induction via __________ do not give it within 4 hours of last dose of cytotec (misoprostol)
do not start pitocin/oxytocin induction within 4 hours of last dose of Cytotec (misoprostol)
are these strong predictors of PTL or PPROM?
- Fetal fibronectin – positive result
- Cervical length measurement via US probe
- Shortening/thinning
- Less than 25 mm before term is abnormal
- History of this type of labor
- Infection
PTL
If water is broken for >18 hours = P____________
- Concern is___________
If water is broken for >18 hours = Prolonged
- Concern is infection!!
is this teaching for cerclage correct:
- small amount of bleeding and cramping in the first 3 days is normal
- report any new onset of lower back pain, pelvic pressure, or change in vaginal discharge (warning signs of impending birth)
yes
are these risks associated with CPD or macrosomia?
Maternal risk
- Prolonged labor
- Increased risk of uterine rupture
- Forceps or vacuum assisted birth
- c/s birth
fetal risk
- increased risk of cord prolapse
- excessive molding of fetal head
- bruising
- nerve trauma
CPD
Cephalopelvic disproportion
___________ is the surgical closure of cervix using suture stitching
used to treat cervical insufficiency and done prophylactically in multiple pregnancies (twins, triplets, etc.)
cerclage
Labor induction vs augmentation
__________ – promote labor in a non-laboring pt
labor induction
Version or Variety?
Turning of the fetus in utero
version
Labor induction or Labor augmentation?
stimulate labor that is naturally occurring but is stalled or not making progress
Labor augmentation
(hypotonic contractions – too little contractions)
which uterine incision(s) are likely to rupture with future VBAC?
low transverse
classical
low vertical
- Classical incision – vertical, mid belly
- Low vertical incision – vertical, low belly
Nursing care:
Pt is being induced with oxytocin and FHR late decel noted
what should nurse do?
- UNCOIL
- Turn oxytocin off
which regional anesthesia Targets a specific nerve to numb a larger area of the pelvis, including the genitals, perineum, and anus?
pudendal block or local analgesic?
pudendal block - Targets a specific nerve (pudendal nerve) to numb a larger area of the pelvis, including the genitals, perineum, and anus.
placental abruption or placenta previa?
Onset - Slow vs abrupt
Bleeding - External vs External or concealed
Color of blood- dark red vs bright red
Pain - painless vs Painful
Abdominal/uterus pain - Painless vs Painful
Uterine tone - firm vs Soft
Uterine contour - Normal vs May be large or change shape
Cramping - one or both?
Uterine activity - one or both?
Onset - PP Slow vs PA abrupt
Bleeding - PP External vs PA External or concealed
Color of blood- PA dark red vs PP bright red
Pain - PP painless vs PA Painful
Abdominal/uterus pain - PP Painless vs PA Painful
Uterine tone - PA Firm vs PP soft
Uterine contour - PP Normal vs PA May be large or change shape
Cramping - both
Uterine activity -both
which 5 things must be documented prior to inducing labor
- Vitals
- Consents
- Reactive non-stress test
- SVE
- Bishop score
- ultra sound
- Vitals
- Consents
- Reactive non-stress test
- SVE
- Bishop score
what is this?
Amniotic fluid gets into the maternal blood circulation
Could be caused by
- a tear in the uterus during placenta separation
- cervical tears under pressure from contracting uterus
embolism blocks blood vessels of the lungs
Amniotic fluid embolism
(Anaphylactoid syndrome)
Possible causes of PROM/PPROM
- Amniocentesis - prenatal test involves taking a small sample of amniotic fluid
- Placenta previa
- Abruptio placentae
- being in a car wreck
- small gestational age
all true
- Amniocentesis
- Placenta previa
- Abruptio placentae
- any trauma
except False - small gestational age not a cause of PROM/PPROM
nursing care: hypertonic/tachysystole contractions or hypotonic contractions?
- assess contractions, vitals, and FHR
- consider CPD
- r/o malpresentation
- maintain adequate hydration
- s/s infection
- oxytocin
nursing care: hypotonic contractions
- assess contractions, vitals, and FHR
- consider CPD
- r/o malpresentation
- maintain adequate hydration
- s/s infection
- oxytocin - stimulate contractions
does Pitocin cause:
- labor induction
- labor augmentation
- contractions to stop
Pitocin
Causes labor induction or labor augmentation
pitocin risks:
- too many/not enough contractions?
- Uterine atony/rupture?
- Water intoxication – hyponatremia/hypernatremia?
- Non-reassuring/ reassuring FHR patterns?
- Increased/ decreased risk for hemorrhage?
Risks
- Tachsystole contractions – too many
- Uterine rupture – from pressure
- Water intoxication – hyponatremia
- Non-reassuring FHR patterns (variable and late decels) – contraindicated to use pit, early decels are ok
- Increased risk for hemorrhage
Nursing care for multiple gestation or AMA?
- Requires more frequent prenatal visits
- Nutrition Education
- Fetal activity
- s/s of preterm labor
- serial US
- anesthesia and blood match readily available
- continuous dual electronic fetal monitoring
- method birth may change once labor begins based on fetal positions
- c/s may be indicated
multiple gestation
Types of ___________ anesthesia:
- Epidural
- Spinal
- Combined spinal-epidural block
- Pudendal block
- Local anesthesia
systemic, regional, general
regional
If the patient is lying on her back for an SVE or foley catheter placement and starts to have late or prolonged decelerations (and is possibly feeling lightheaded and nauseated), which UNCOIL would you implement first?
UNDO cause = you would first turn her to her side because the cause was likely supine hypotension syndrome.
If not immediately resolved you would start implementing the other UNCOIL measures.
is it contraindicated to use pitocin with FHR pattern:
- variable decelerations
- late decelerations
- early decelerations
contraindicated to use pit with Non-reassuring FHR patterns
(such as variable and late decels)
early decels are ok
labor induction
Advantage
- Labor will usually occur in ___ - _____ hours
Disadvantage
- Contractions may begin _______ gradual
- _____________ uterine contractions
- _____________ bloody discharge
Advantage
- Labor will usually occur in 24-48 hours
Disadvantage
- Contractions may begin less gradual
- Dysfunctional uterine contractions – too many contractions, may be caused by oxytocin
- Increased bloody discharge
Premature rupture of membranes (PROM) or Preterm premature rupture of membranes (PPROM) :
- water breaks before the onset of labor (no contractions)
- 37 weeks or greater
Premature rupture of membranes (PROM)
