Week 6 Flashcards
Birthing complications
Three types of cephalic presentation are
vertex, brow and face
Indication for external cephalic version
breech position to reposition to vertex
what are some ways you can assess before you do an external cephalic version?
Ultrasound and Leopold maneuver
what is the medical management for external cephalic version?
US, informed consent,
tocolysis (meds),
neuraxial analgesia,
NST or BPP,
cesarean services must be readily available
what are some risks to external cephalic version?
Placental abruption, umbilical cord prolapse, ROM, still birth, fetomaternal hemorrhage, severe variable decelerations
What is the procedure in which the fetus is rotated from the breech to the cephalic presentation?
External cephalic version
When is local anesthesia injected?
Second stage of labor, immediately before delivery Anesthetizes local tissue for episiotomy and repair
what are contraindications to external cephalic version?
Placental abnormalities because it can result in hemorrhage or cord prolapse
Where is local anesthesia injected?
Anesthetic injected into perineum at episiotomy site
What would you monitor for when someone has a regional block?
Return of sensation
Increased welling
s/s of infection
urinary retention
What are some adverse risks to local anesthesia?
Risk of a hematoma
Risk of infection
When would you give a regional block?
Anesthetize vulva, lower vagina and part of perineum for episiotomy and use of low forceps
Where is a regional block placed?
Pudendal nerve near the ischial spines
When is the epidural block injected?
First stage and/or second stage of labor
What are some adverse risks to regional anesthesia?
Risk of a hematoma
Risk of infection
Risk of local anesthetic toxicity
What is the anesthetic injected in the pudendal nerve (close to the ischial spines) via needle guide known as “trumpet”
Regional
Where is the epidural block injected?
Spot outside dura mater between the dura and spinal canal via an epidural catheter
What is the most common complication of epidural?
Hypotension
what are some side effects of an epidural?
Nausea, vomiting, pruritis, respiratory depression, alterations and fetal heart rate
What are some pre-anesthesia care?
Obtain consent. Check lab values—especially for bleeding or clotting abnormalities, platelet count. IV fluid bolus with normal saline or lactated Ringer’s. Ensure emergency equipment is available. Do time-out procedure verification
What are some post-anesthesia care?
Monitor maternal vital signs and FHR every 5 min initially and after every re-bolus then every 15 minutes and manage hypotension or alterations in FHR.
Urinary retention is common and catheterization may be needed. Assess pain and level of sensation and motor loss. Position woman as needed
Assess for itching, nausea and vomiting, and headache and administer meds PRN.
When catheter discontinued, note intact tip when removed.
What are indications for general anesthesia?
Risk for fetal depression
Risk for uterine relaxation
Risk for maternal vomiting and aspiration
What about anesthesia might be passed into the infant?
Fetal acidemia
lack of continuing progress toward birth for _(time)__ with regional anesthesia or _(time)__ without regional analgesia or
anesthesia and for multiparous women as a lack of
continuing progress for _(time)__ with regional anesthesia or _(time)__ our without regional anesthesia.
3, 2
2, 1
What is a main reason for amnioinfusion?
Intrauterine resuscitation interventions?
What FHR can amnioinfusion correct? How?
Variable decelerations by correcting cord compression from oligohydramnios
what is the procedure we’re where room temperature saline or lactated ringer is infused into the uterus transcervically via an IUPC to increase amniotic fluid to cushion the biblical cord and reduce compression?
Amnioinfusion
what is the medical management of variable decelerations?
Amnioinfusion, tocolytics, and delivery
What is the leading indication for primary cesarean birth in the US?
Labor distocia
abnormal labor results from abnormalities of what three p’s?
Power, passenger, pelvis
what is it called when there is abnormal uterine contractions that prevent normal progress of cervical dilation or descent of the fetus?
Dysfunctional labor
what are two practical classifications of abnormal labor in the active phase?
Protraction disorders where there is slower than normal labor
Arrest disorders with complete cessation of uterine contractions
what are some risk factors for dystocia?
Congenital uterine abnormalities such as bicornuate uterus
male presentation of a fetus such as occiput posterior or face presentation
cephalopelvic disproportion
tachysystole the uterus with oxytocin
Maternal fatigue and dehydration
Administration of analgesic or anesthesia early in labor
Extreme maternal fear or exhaustion which can result in catecholamine release interfering with contractility
what are two types of uterine dystocia?
Hypotonic uterine dysfunction
hypertonic uterine dysfunction
what is the term for uncoordinated uterine activity where contractions are frequent and painful but ineffective in promoting dilation and effacement?
Hypertonic uterine dysfunction
what is it called when there is ineffective contractions during early labor?
Prodromal labor
what are the causing risk factors of hypertonic uterine dysfunction?
nulliparous women
what are some risk factors related to hypertonic uterine dysfunction to the fetus?
Intolerance of labor
Asphyxia related to decreased placental perfusion
what are some findings for hypertonic uterine dysfunction?
Painful frequent uterine contractions
Inadequate uterine relaxation between contractions
Little cervical changes
May be category two or category 3
what are some nursing actions for hypertonic uterine dysfunction?
Promote rest to break the pattern of contractions
administer demerol or morphine to promote sleep and prevent exhaustion
hydrate
warm shower or tub bath
Quiet environment
what is it called when the pressure of contractions is insufficient and less than 25mm Hg?
Hypotonic uterine dysfunction
what is the strength of contractions to have sufficient pressure to promote cervical dilation and Effacement?
25 or more
what are some causes or risk factors that increase the chance of hypotonic uterine dysfunction?
Multiparous womaen
Extreme fear which can release catecholamine
what are the assessment findings for hypotonic uterine dysfunction?
what are the assessment findings for hypotonic uterine dysfunction?
what are some medical managements for hypotonic uterine dysfunction?
Determine the cause
Augment with oxytocin
Perform amniotomy
Perform cesarean when other interventions have failed
what are some nursing actions for hypotonic uterine dysfunction?
Assess contractions and maternal and fetal status
ambulate and change position to promote comfort
Hydrate with Ivy or PO as dehydration can cause dysfunctional labor
Administer IV fluids to correct maternal hypotension
augment with oxytocin
why is it important to not do a sterile exam and maintain perineal cleanliness during prolonged labor?
There is a risk of infection with prolonged labor
how frequently do hypertonic uterine contractions happen and last for?
Occurs every two minutes or more frequently lasting greater than 60 seconds and strong
how would you describe contractions occurring every 2 minutes or more frequently lasting greater than 60 sec and strong
Occurs every two minutes or more frequently lasting greater than 60 seconds and strong
how would you describe contractions occurring every 2 minutes or more frequently lasting greater than 60 sec and strong
hypertonic or tetanic uterine contractions
how would you categorize rapid cervical dilation that labor is less than three hours?
precipitous labor
how often should you check contractions and fetal heart rate during a precipitous labor and birth?
Every 15 minutes
Precipitous labor places the woman at risk for what?
Postpartum hemorrhage related to uterine anatomy or lacerations
What are some risks to the fetus of precipitous labor?
Hypoxia and risk for CNS depression
What should you do as a nurse to prepare for a precipitous labor?
Remain in the room who are having rapid birth
anticipate potential complications such as hemorrhage and lacerations
assess dilation and contractions
anticipate potential neonatal complications such as hypoxia and CNS depression
Why might a fetus have hypoxia with precipitous labor?
Uterine contractions are strong
What is the difference between induction and augmentation
Induction is deliberate stimulation of contractions before spontaneous labor has started. And augmentation needs assessment when spontaneous contractions have not resulted in progressive cervical dilation or descent
Fetal dystocia may be caused by what factors?
excessive fetal size (4,500g+)
malpresentation like face, brow, or breech
multifetal pregnancy
fetal anomalies like hydrocephalus
What is the best position for the baby to be born?
Head flexed
Presenting anterior to the women’s pelvis (occiput anterior position)
Complications of fetal dystocia are:
■ Neonatal asphyxia related to prolonged labor
■ Fetal injuries, such as bruising
■ Maternal lacerations
■ Cephalopelvic disproportion (CPD)
What fetal anomalies can cause fetal dystocia?
Hydrocephalus
what kind of fetal presentation puts the baby at risk for fetal dystocia?
Brow, face, breach
What is the normal anteroposterior diameter?
14 cm
occiput posterior can cause what to the mother?
Prolong labor and prolonged second stage
severe back pain
a condition in which the size, shape, or position of the fetal head prevents it from passing through the lateral aspect of the maternal pelvis or when the maternal pelvis is of a size or shape that prevents the descent of the fetus through the pelvis
Cephalopelvic disproportion
Cephalopelvic disproportion is a condition in which the _____, _____, or ____ of the fetal head prevents it from passing through the ____ aspect of the maternal pelvis or when the maternal pelvis is of a size or shape that prevents the descent of the fetus through the pelvis
size, shape, or position
lateral
babies born before completed 37 weeks are at risk for what complications?
Prematurity
Cesarean
Hemorrhage
Infection
Breathing problems
Feeding issues
Jaundice
Low blood sugar
Insufficient stabilizing their own body temperature
what cascade of interventions does induction of Labor lead to?
IV fluids
Activity restriction or bed rest
More frequent or continuous fetal monitoring
Increased pain medication use and epidural anesthesia
Amniotomy
Prolonged stay in the labor unit
what are some things to consider when choosing a induction versus spontaneous labor
parity
Status some membranes
Status of cervix
History of previous cesarean births
Contras for oxytocin induction
■ Any contraindications for vaginal birth
■ Previous vertical (classical) uterine scar or prior transfundal uterine scar
■ Placental abnormalities such as complete placenta previa or vasoprevia
■ Abnormal fetal position
■ Umbilical cord prolapse
■ Active genital herpes
■ Pelvic abnormalities
Risks Associated With Inductions
Tachysystole leading to Category II (indeterminate) or Category III (abnormal) FHR pattern ( primary complication)
Side effects of oxytocin use are primarily dose related
tachysystole and subsequent FHR decelerations are common side effects
Water intoxication can occur with high concentrations of oxytocin with large quantities of hypotonic solutions
A uterine response occurs to oxytocin in ____minutes, with a half-life of __ minutes.
3–5, 10
What is the most common induction agent?
oxytocin
what are some medical indications of the mother that can result in oxytocin induced labor?
Diabetes, renal disease, chronic pulmonary disease, cardiac disease, chronic hypertension
what are some indications not related to the mother’s health that results in oxytocin induced labor?
Post term pregnancy,
Preeclampsia
premature rupture of membranes
Chorioamnionitis
Fetal stress or compromise such as IUGR and oligohyd.
Fetal demise
History of rapid labors/distance from hospital
Psychosocial considerations
It is estimated that ___%–___% of inductions are elective or nonmedical.
25%–50%
Side effects of oxytocin use are typically caused by what?
Dosing problems
What is the goal of administering oxytocin in labor
goal of oxytocin use in labor is to establish uterine contraction patterns that promote cervical dilation of about 1 cm/hr once in active labor.
Oxytocin is administered ________ and is _______ to a ________at the port most _______ to the venous site
Intravenously
Piggybacked
mainline IV solution
proximal
Oxytocin is ____ infused via a _____
Always
Pump
When should oxytocin be stopped?
Once active labor is established, oxytocin should be discontinued to avoid downregulation.
where is endogenous oxytocin synthesized and released?
In the hypothalamus that is transported into the posterior lobe of the pituitary glandTrue
Prior to elective induction, fetal maturity must be confirmed to be _____ weeks or greater by the following:
39
1. Ultrasound before 20 weeks’ gestation confirms gestational age of 39 weeks or greater.
2. Fetal heart tones have been documented as present by Doppler for 30 weeks.
3. It has been 36 weeks since a positive serum or urine pregnancy test was confirmed.
Avoid ____ because it frequently results in _______or _____fetal heart rate pattern.
Tachysystole
Category II or III
What are nursing actions for a Category II or Category FHR pattern from oxytocin induction?
■ Discontinue.
■ Change maternal position to lateral.
■ Initiate IV hydration of at least 500 mL LR
■ Administer O2 by nonrebreather mask at 10 L/min.
■ Consider terbutaline if no response
■ Notify the provider and request evaluations for Category III abnormal FHR.
What is considered tachysystole?
More than 5 UCs in 10 minutes over 30-minute window
Series of single UCs lasting 2 minutes or longer
UCs occurring within 1 minute of each other
What two diseases can cause chorioamnionitis?
GBS and Bacterial vaginosis
GBS and Bacterial vaginosis
intrauterine inflammation or Triple IClar without a clear source
What is chorioanmiontis aka?
intrauterine inflammation or Triple I
What is suspected Triple I?
at term of pregnancy can have an infectious and/or inflammatory origin and is associated with adverse outcomes
What are some complications of chorioamnionitis in fetus?
acute neonatal morbidity like neonatal pneumonia, meningitis, sepsis, and death,
long-term infant complications such as bronchopulmonary dysplasia and cerebral palsy
What are suspected Tripe I results?
Baseline fetal tachycardia (greater than 160 beats per minute [bpm] for 10 minutes or longer, excluding accelerations, decelerations, and periods of marked variability) Maternal WBC counts greater than 15,000 per mm3 in the absence of corticosteroids Definite purulent fluid from the cervical os
Risk factors that can cause chorioamnionitis
Migration of cervicovaginal flora through the cervical canal
Prolonged ROM lasts greater than 24 hours.
Low parity
multiple digital examinations
use of internal uterine and fetal monitors
meconium-stained amniotic fluid, and presence of genital tract pathogens
What temperature is an isolated maternal fever?
Oral temp of 102.2 F or greater on any one occasion
Characteristic clinical signs of chorioamnionitis:
Maternal fever (intrapartum temperature higher than 100.4°F [37.8°C])
Significant maternal tachycardia (greater than 120 bpm) Fetal tachycardia (greater than 160 to 180 bpm)
Purulent or foul-smelling amniotic fluid or vaginal discharge Uterine tenderness
Maternal leukocytosis (total blood leukocyte count greater than 15,000 to 18,000 cells/μL)
Hypotension Diaphoresis Cool or clammy skin
What is a positive Triple I
Amniocentesis-proven infection through a positive Gram stain Low glucose or positive amniotic fluid culture Placental pathology revealing diagnostic features of infection
What stimulates prostaglandin release resulting in cervical ripening?
Inflammatory cytokines or bacterial endotoxins
What is the medical management of chorioamnionitis?
Communicate about any abnormal v/s
Abx
antipyretics.
What is the test used for cervical status?
Bishop score
What is the process of physical softening, thinning, and dilating of the cervix in preparation for labor and birth
Cervical ripening
What are the three changes that happens to the cervix to prepare for labor and birth.
ripening, effacement, and dilation
What is a favorable cervix according to the Bishop score?
8 or more
What is an unfavorable cervix according to the Bishop score?
6 or less
What are some mechanical cervical ripening?
hygroscopic dilators (laminaria, Lamicel, or Dilapan) transcervical balloon catheters (Cook balloon or deflated Foley catheter)
Cervical ripening is associated with a higher risk of __________ when labor is induced compared with spontaneous labor
cesarean delivery
Pharmacological methods of cervical ripening
cervidil (dinoprostone insert)
misoprostol PGE1 (cytotec)
What are the indications of mechanical cervical ripening?
When the woman has little or no cervical effacement When pharmacological methods are contraindicated, such as women with prior uterine incision
What might happen if a woman has a Bishop score of less than six?
Might use a cervical ripening procedure
How long after using dinoprostone gel would oxytocin be delayed?
6-12 hours after
Risks Associated With Mechanical Cervical Ripening
Higher rate of infection
PROM
How long does a mechanical dilator stay in place?
6-12 hours before removal or assessment
Contraindications for mechanical cervical ripening
Active herpes
Unexplained vaginal bleeding
Placenta previa
Vasa previa
Ruptured membranes
Prior c-section
How long after misoprostol should oxytocin be delayed?
At least four hours
What kind of hormone is used for pharmacological methods of cervical ripening?
Prostaglandins
How long after cervidil removal can the woman be given oxytocin?
30-60 minutes
Contraindications for pharmacological cervical ripening
Vertical uterine incision
Active herpes
Baby in breech position
What are the four risks for amniotomy
variable decelerations
bleeding
umbilical cord prolapse
intraamniotic infection
What are the two cervical ripening agents that are no recommended for women with a previous uterine scar?
Insertable cervidil
Misoprostol pge
What is AROM?
Artificial Rupture of Membranes
What is AROM used for?
used to induce or augment labor during a sterile vaginal exam, or shorten labor
Amniotomy in early labor increases the risk of _____ for __________.
cesarean birth
abnormal FHR
What do you assess immediately after AROM?
FHR and UC
Color, amount, and odor of amniotic fluid
cervical status and fetal station
temperature every two hours
AROM is most effective in multiparous women who are __________.
dilated to 2 cm or more.
What is labor augmentation
stimulation of ineffective UCs after the onset of spontaneous labor to manage labor dystocia
What are contraindications to amniotomy and why?
■ Fetal head not engaged in the maternal pelvis (cord prolapse)
■ Maternal infection such as HIV and active genital herpes (infection)
Vacuum cup should not be on the fetal head for longer than ____
15-20 minutes
What are some things to confirm before vacuuming?
Cervix fully dilated and retracted
Membranes ruptured
Engagement of the fetal head
Position of the fetal head has been determined
Weight estimated
Adequate anesthesia
Pelvis is adequate
Fetus older than 34 wks, engaged head, and at least 0 station
Indications to forceps use
Fetal head Is engaged and cervix dilated
No suspicion of immediate or potential fetal compromise
To shorten 2nd stage for maternal benefit
Prolonged second stage
High level of regional anesthesia
Maternal cardiac of pulmonary disease
What is the stimulation of ineffective UCs AFTER the onset of spontaneous labor to manage labor dystocia
Labor augmentation
What are some advantages of vacuum over forceps?
Easier application
Less anesthesia required
Less maternal soft tissue damage
Fewer fetal injuries
Forceps risk for newborn
facial lacerations
facial nerve palsy
corneal abrasions and external ocular trauma
skull fracture
intracranial hemorrhage/subdural hematoma
facial lacerations
facial nerve palsy
corneal abrasions and external ocular trauma
skull fracture
intracranial hemorrhage
facial lacerations
facial nerve palsy
corneal abrasions and external ocular trauma
skull fracture
intracranial hemorrhage
How often do you assess the temperature after an anmiotomy?
Every two hours
What are some indications for vacuuming?
maternal exhaustion and an inability to push effectively
medical indications such as maternal cardiac disease and a need to avoid pushing in the second stage of labor
prolonged second stage of labor (nulliparous woman with lack of progress for 3 hrs w/ anes or 2 w/o anes.
arrest of descent, or rotation of the fetal head
nonreassuring FHR patterns in the second stage of labor
Risks for the Newborn with vacuum
Cephalohematoma (15%
Laceration
Subgaleal or intracranial, or retinal hemorrhage
Increased rates of hyperbilirubinemia
Low forceps are used in what instance?
Areused when the skull is at +2 station or lower in the maternal pelvis and not on the pelvic floor and rotation is greater than 45 degrees (
Amniotic fluid embolism (AFE), also known as
anaphylactic syndrome
Amniotic fluid is made up of what?
maternal extracellular fluid, fetal urine, fetal squamous cells, lanugo, vernix caseosa, mucin, meconium, arachidonic acid metabolites, and, late in pregnancy, increased concentrations of prostaglandins
What are the guidelines for vacuum application?
Engaged fetal head and complete dilation
Maximum of three tries in 15 minutes
Cup detachment means warning sign for too much pressure/ineffective force
Proceed when cesarean birth if necessary.
What is anaphylactic syndrome?
amniotic fluid that contains fetal cells, lanugo, and vernix enters the maternal vascular system and results in cardio respiratory collapse
Risks for the Woman with vacuum
Vaginal and cervical lacerations
Extension of episiotomy (3rd and 4th degree perineal tears)
Hemorrhage related to uterine atony or rupture
Bladder trauma
Perineal wound infection
When are outlet forceps used?
when the head is visible on the perineum and the skull has reached the pelvic floor, and rotation is less than 45 degrees
When can AFE occur?
during pregnancy, labor, birth, or the first 24 hours postbirth
How old must a fetus be to deliver with forceps?
Use only on a fetus that is at least 36 weeks’ gestation
Forceps risk for mother
Vaginal and cervical lacerations; risk of 3rd- and 4th-degree perineal tears compared with patients who had a spontaneous delivery.
Extension of episiotomy
Hemorrhage related to uterine atony and uterine rupture.
Perineal hematoma Bladder trauma Perineal wound infection
What are the two types of operative vaginal birth?
Vacuum assisted and forceps assisted
What is the indication of labor augmentation?
to strengthen and regulate UCs, to shorten length of labor
Prolonged second stage for nulliparous woman
lack of continuing progress for 3 hours with regional anesthesia, or for 2 hours without anesthesia
Prolonged second stage for multiparous woman
lack of continuous progress for 2 hours with regional anesthesia, or for 1 hour without regional anesthesia
What is the ideal goal for contractions induced by oxytocin?
Frequency 2-3 minutes
Intensity 60-90
Duration 45-60 sec
amniotic fluid may enter the maternal circulation in what three ways
(1) through the endocervix following rupture of amniotic membranes
(2) at the site of placental separation
(3) at the site of uterine trauma, often lacerations that occur during normal labor, fetal descent, and birth (placental abruption for example)
Why should you have two IV sites for AFE?
One for blood and one for fluids
AFE classically consists of hypoxia from _____ and ________,________, and ________, and ________,
acute lung injury and transient pulmonary hypertension, hypotension, and cardiac arrest and coagulopathy
What does a sudden presentation of dyspnea lead to in anaphylactic syndrome?
Massive fibrinolysis
AFE can lead to what in the mother?
Postpartum hemorrhage with severe DIC
Hypoxic encephalopathy
Signs and symptoms of anaphylactoid syndrome are related to _____ and _______.
anaphylactic shock
cardiopulmonary collapse
anaphylactoid reaction leads to what complications
Acute pulmonary hypertension
Rt and lt. ventricular failure
Acute respiratory failure
DIC
sudden hypoxemia and shock can evolve rapidly into what?
Cardiorespiratory collapse
Risk factors of AFE?
older maternal age
multiple pregnancy
placenta previa
labor induction
cesarean delivery
instrumental vaginal delivery
cervical or uterine trauma
eclampsia
What is in stage one of AFE?
Amniotic fluid and fetal cells enter the maternal circulation → release of endogenous mediators → pulmonary vasospasm and pulmonary hypotension → elevated right ventricular pressure and hypoxia → myocardial and pulmonary capillary damage → left heart failure and acute respiratory distress
How would you recognize AFE?
rapid onset of respiratory distress during labor, delivery, or 30 minutes postdelivery
severe hypoxia; hypotension; cyanosis; loss of consciousness
foaming at the mouth
pulmonary edema
uncontrolled bleeding from the uterus, IV sites, or any other incisions due to coagulopathy
seizures, cardiac arrest
prolonged late decelerations or bradycardia
What is in stage two of AFE?
Hemorrhage and DIC
Medical management of AFE
V
entry points of amniotic fluid are:
Cervix following rupture of amniotic membranes
Site of placental separation
Site of uterine trauma—lacerations that occur during the labor and delivery process
VBAC may decrease the risk of what maternal consequences related to multiple cesarean deliveriesWhat are VBAC indication?
Hysterectomy
bowel or bladder injury
transfusion
infection
abnormal placentation such as placenta previa and placenta accreta
What is the opportunity to achieve a VBAC called?
trial of labor after cesarean (TOLAC)
Women with what have a higher rate of failed VBAC and infection.
obesity
What are VBAC indication?
One or two prior low transverse cesarean births with no other uterine scars
Clinically adequate pelvis
Physician and OR team immediately available to perform emergent cesarean birth.
Health advantages of VBC
lower rates of hemorrhage, thromboembolism and infection
shorter recovery
Contraindications of VBAC
Prior vertical (classical) or T-shaped uterine incision or other uterine surgery
Previous uterine rupture
Pelvic abnormalities
Medical or obstetric complications that preclude a vaginal birth
Inability to perform an emergent cesarean birth if necessary because of insufficient personnel such as surgeons, anesthesia, or facility
Benefits of TOLAC resulting in VBAC include
Shorter hospital stays and postpartum recovery
Fewer complications, such as postpartum fever, wound or uterine infection, thromboembolism, and transfusion.
Fewer neonatal breathing problems
Women with epidurals may feel ____ and ____ during the procedure because epidurals are not as _____ and do not provide full _____ and _____ _____.
Tugging, pulling
Dense
Sensory and motor block
Which is the “bikini cut” incision?
Pfannenstiel incision where ; transverse skin incision made at the level of the pubic hairline
What are some expected finding of the patient during a c-section?
Increased anxiety levels
Concerns related to potential injury from anesthesia and or surgery
Woman may feel abdominal pressure as the neonate is being delivered
Risks Associated With VBAC
Uterine rupture and complications w/ rupture
Failed TOLAC is associated with more complications than elective repeat cesarean delivery.
Uterine rupture or dehiscence
Neonatal morbidity is higher in the setting of a failed TOLAC than VBAC
Which prior cesarean incision is a contraindication for VBAC and why?
Prior vertical (classical) or T-shaped uterine incision because the uterus can rupture
Medical management of c-section preoperative
obtain informed consent
draw labs (CBC, blood type, Rh)
education
Experts suggest a TOLAC to attempt a VBAC is an acceptable option for a woman who has undergone ______ delivery with _______ incision
one prior cesarean
a low transverse uterine
Waiting for spontaneous labor and avoiding use of ____ and ___ reduces the risk of _____.
prostaglandins and oxytocin
uterine rupture
What to review before surgery
History
include patient
family member
support person in plan of care
individualized care
allow 1 support person to be present during surgery
What are possible complications of c-sections?
Hemorrhage
Bladder, ureters, and bowel trauma
Maternal respiratory depression related to anesthesia
Maternal hypotension related to anesthesia, which increases the risk for fetal distress
Inadvertent injection of the anesthetic agent into the maternal bloodstream
What happens if there is inadvertent injection of the anesthetic agent into the maternal bloodstream?
woman experiences ringing in her ears, metallic taste in her mouth, and hypotension that can lead to unconsciousness and cardiac arrest
The determination of type of anesthesia is based on what?
Is the safest and most comfortable for the woman
Has the least effect on the fetus/neonate
Provides the optimal conditions for the surgery
Why is spinal anesthesia is the preferred method for scheduled cesarean sections?
Spinal anesthesia, which is faster to place, provides a full sensory and motor block
General anesthesia is used for what situations?
Rapid delivery is imperative
Severe hemorrhage
Seizures
Failed Spinal
What is a classical cesarean delivery?
vertical abdominal wall skin incision and vertical incision in the body of the uterus
rare, used in emergent cesarean births when immediate delivery is critical
placenta is manually removed
Nursing actions 24 hrs postop to discharge
Assess for involutional changes and complications
Monitor v/s every eight hours
Incentive spirometer or deep breath and cough every 2 hrs
Monitor for hemorrhage and infection
Assess fundus and lochia
Remove foley around 8-12 hrs after surgery
Contraindications for epidural or spinal anesthesia
The woman’s refusal or inability to cooperate with the procedure
Increased intracranial pressure
Infection at the site of needle insertion
Low platelet count
Uncorrected maternal hypovolemia
Expected Assessment Findings of c-section
Normal v/s
Lochia is moderate to scant
Firm fundus and midline
Dressing is dry
Catheter is draining clear/yellow
IV has no infiltration or inflammation
Pain is less than 3
Gradually regains full motor and sensory function
Food feeding
What are some nursing actions preop cesarean?
Assess FHR
Resposition to left lateral tilt
Apply grounding device
Insert foley
Perform abdominal skin prep
Check equipment
Immediate postop care of c-section First 24 hours after birth include
IV therapy
Medications such as analgesics and stool softeners
Antibiotic therapy for the woman at risk for infection related to prolonged rupture of membranes, prolonged labor, or elevated temperature during labor
Progression of diet
Removal of the Foley catheter
Activity level
What are some SE of morphine?
Itching
Nausea
Decreased respirations
How much should a woman void after catheter removal?
200-300 cc
What refers to difficulty encountered during delivery of the shoulders after the birth of the head?
Shoulder dystocia
What should you do to the infant after a c-section?
Allow the parents to see or touch the baby after it is born, or hold and skin-to-skin if stable
It’s when the head goes back against the mother’s perineum after the head has already been delivered
Impaction of the fetal shoulders may lead to a prolonged delivery time of more than _____.
Neonatal morbidity of shoulder dystocia includes:
Brachial plexus injuries
Clavicle fracture
Neurological injury
Asphyxia
Death
The usual hospital stay for c-section
3-5 days
Risk Factors causing Shoulder Dystocia
Fetal macrosomia (wt >4,500 grams)
Maternal diabetes
History of shoulder dystocia
Prolonged second stage
Excessive weight gain
What specific part of the shoulders get stuck with shoulder dystocia?
anterior shoulder or, more rarely, both shoulders become impacted above the pelvic rimWhat is a turtle sign?
Medical Management of shoulder dystocia
Downward traction may be applied to the fetal head w/ suprapubic pressure
Extend the midline episiotomy to obtain room for maneuvers.
McRoberts maneuver initially
Woods corkscrew maneuver
Deliver the posterior shoulder by sweeping the posterior arm across the fetus’s chest followed by delivery of the arm.
What is the Woods corkscrew maneuver?
progressively rotates the posterior shoulder 180 degrees to disimpact the anterior shoulder.
Risks Associated With Shoulder Dystocia
Delay in delivery of the shoulders results in compression of the fetal neck by the maternal pelvis, which impairs fetal circulation and results in possible increased intracranial pressure, anoxia, asphyxia, and brain damage.
Brachial plexus injury and clavicle fracture in the neonate can also occur.
Maternal complications include lacerations, infection, bladder injury, or postpartum hemorrhage.
Zavanelli maneuver
cephalic replacement into the pelvis and then cesarean delivery, for catastrophic cases only
What is the McRoberts maneuver?
Two assistants, each grasp a maternal leg and then sharply flexes the thigh back against the maternal abdomen
Causes cephalad rotation of the symphysis pubis and flattening of the lumbar lordosis that can free the impacted shoulder
Why might shoulder dystocia cause asphyxia?
A more than 5- minute delay in head to body interval may result in fetal hypoxemia and acidocis
Additional fetal risks of post-term pregnancies include:
macrosomia, which increases the likelihood of operative vaginal deliveries, cesarean deliveries, and shoulder dystocia
neonatal seizures
meconium aspiration syndrome (MAS)
low 5-minute Apgar scores
When might a c-section be planned to prevent shoulder dystocia?
suspected fetal macrosomia with an estimated fetal weight exceeding 5,000 grams in women without diabetes and 4,500 grams in women with diabetes
risk of stillbirth increases beyond ____ weeks.
41
Suprapubic pressure in fetal dystocia is what?
Pressure is applied above the pubic bone with the palm or fist and laterally, and then aduct and rotate the anterior shoulder
. Fundal pressure should be avoided to prevent impaction of shoulder and cause uterine rupture
What are some nursing actions for a shoulder dystocia?
Insert straight cath if distended
Mother should not push
Notify neonatal team and prepare for neonatal resuscitation
Which is more common post term? Oligohydramnios or polyhydramnios
Oligohydramnios
Meconium-stained fluid occurs in __-__% of post-term pregnancies
25%–30%
Oligohydramnios in post term has been associated with what?
Cord compression, GHR abnormalities
meconium-stained amniotic fluid
fetal acidosis
What are assessment finding of post-term pregnancy and birth?
Category II or III FHR related to decreased amniotic fluid and uteroplacental insufficiency
Pregnancy with aging placenta
Meconium-stained fluid
Women report increased anxiety and frustration with prolonged pregnancy
Fetal macrosomia
Aspiration of meconium results in what complications?
. Aspiration of meconium results in respiratory distress that in severe cases can be life-threatening.
It induces hypoxia via four major pulmonary effects:
airway obstruction
surfactant dysfunction
chemical pneumonitis
pulmonary hypertension
Meconium stool begins to form during the ___gestational month and is the first stool eliminated by the neonate. It is ___, ___, ___, and ___. It is first passed within __-__ hours.
4th
sticky, thick, black, and odorless
24-48 hrs.
Signs of post-term birth
Still birth or neonatal dea
Macrosomnia
Fetal dysmaturity
Restricted growth
Decreased subcut fat
Lack of vernix and lanugo
Meconium staining of the amniotic fluid, skin, membranes and umbilical cord
Post-term medical management
Antenatal surveillance ■ Induction of labor offered at 41 weeks of gestation
What are s/s off pulmonary embolism?
dyspnea, tachypnea, chest tightness, shortness of breath, hypotension, and decreasing oxygen saturation levels.
Leg pain can lead to PE
What is called when the cord lies below the presenting part of the fetus.
Umbilical cord prolapse
Risk factors that cause Prolapse of the Umbilical Cord
Malpresentation of the fetus (such as breech)
Unengaged presenting part
Polyhydramnios
Small or preterm fetus
Multiple gestation
High parity
Which condition would you position the patient on hands and knees to help rotate fetus?
Labor dystocia
What is Occult prolapse?
cord is palpated through the membranes but does not drop into the vagina
Risks Associated With Prolapse of the Umbilical Cord
rapid deterioration in fetal perfusion and oxygenation
An entrapped cord can results in what to the FHR?
bradycardia
Assessment Findings of umbilical cord prolapse
Sudden fetal bradycardia (i.e., prolonged decelerations) ■ Prolapsed umbilical cord that may be felt with a SVE or visualized in or protruding from the vagina
Risk factors r/t pregnancy of cord prolapse:
The primary iatrogenic cause is AROM.
Polyhydramnios
multiple gestation
SROM
preterm ROM
grand multiparity
Medical Management of cord prolapse
Vaginal birth or operative vaginal delivery may be attempted if birth is imminent.
c-section
Nursing Actions for prolapsed cord
hand remains in the vagina, lifting the presenting part off the cord until delivery by cesarean
Recommend position changes such a knee-chest position or Trendelenburg to try to relieve pressure
O2
Discontinue oxytocin
IV fluid hydration bolus
Administer tocolytic
Risks with umbilical cord prolapse
rapid deterioration in fetal perfusion
oxygenation
fetal hypoxia; if not treated swiftly,
long-term sequela, disability, or death
Overt vs occult prolapse
Occult is not visible nor palpable and with over, the cord presents before the fetus and is visible or palpable within the vagina or past the labia
In which condition would you have the mom in a knee-chest or Trendelenburg
Prolapsed umbilical cord
Which condition would you call for assistance?
Prolapsed cord, uterine rupture
In which condition would you encourage the patient to remain in a side-lying position
Precipitous labor
Which condition would you administer oxygen?
Uterine rupture and prolapsed umbilical cord
Prolapse of the umbilical cord can lead to compression, causing FHR _______including severe sudden _____; this often occurs with prolonged ______or recurrent moderate-to-severe ___ decelerations.
Decelerations
Deceleration
Bradycardia
variable
For which condition would you monitor for signs of maternal hemorrhage or postpartum hemorrhage?
Precipitous labor, and uterine rupture
What is associated with postpartum hemorrhage that can lead to
Increased morbidity and mortality rates are associated with postpartum hemorrhage, which can result in the need for emergency hysterectomy, hypovolemic shock, disseminated intravascular coagulation, and renal and hepatic failure.
For which condition would you assist with amniotomy?
Labor dystocia
