OB UNIT 3 Preeclampsia, gestational diabetes, and labor complications
A client at 27 weeks gestation has been diagnosed with gestational diabetes. What therapy will most likely be ordered for this client?
diet control and exercise
Friedman's Curve
graph used to plot rates of cervical dilation and fetal descent during active labor
Amnioinfusion
introduction of a solution into the amniotic sac; an isotonic solution is most commonly used to relieve fetal distress -must be warmed -bolus 500ml over 1 hr Risk: Uterine rupture (check for and document return of fluid) Infection
euglycemia
normal level of sugar in the blood
Glucose metabolism is profoundly affected during pregnancy because
placental hormones are antagonistic to insulin, resulting in insulin resistance.
ECV
turns fetus from breech to vertex 37 to 38 weeks FHR and U/S record continuously Tocolytic maybe used to relax uterus -Contraindications Multiple gestation Oligohydramnios Third trimester bleeding
A client who has been diagnosed as having Preeclampsia with severe features is receiving magnesium sulfate via IV pump. What medication must the nurse have immediately available?
Calcium gluconate
A nurse is caring for a client who is receiving IV magnesium sulfate, which medication should the nurse anticipate administering if magnesium sulfate toxicity is suspected
Calcium gluconate
Maternal risk due to fetal macrosomia
Cephalopelvic disproportion CPD Dysfunctional labor Prolonged labor Soft tissue laceration during vaginal birth Postpartum hemorrhage
Surgical therapies for cervical insufficiency
Cerclage-surgical procedure in which a stitch is placed in the cervix to prevent spontaneous abortion or premature birth Elective cerclage -May be outpatient procedure -May require hospitalization with discharge after 24 to 48 hours Emergent cerclage -Require hospitalization for 5-7 days Abdominal cerclage After 37 completed weeks gestation, suture may be cut and vaginal birth permitted or the suture may be left in place and a cesarean birth performed
Eclampsia
Characterized by grand mal or tonic clonic seizure May occur before onset of labor, during labor, or early in postpartum period Women may have one or more seizures Cause is preeclampsia and it can happen 6-12 weeks postpartum
Classification of heart disease
Class I No limitations of physical activity Ordinary physical activity does not precipitate, cardiovascular symptoms, such as dyspnea, angina, fatigue, or palpitations Class II Slight limitation of physical activity Ordinary physical activity, precipitates cardiovascular symptoms, patient comfortable at rest Class III Activity limited Less than ordinary, physical activity precipitates symptoms, patient comfortable at rest Class IV Discomfort with any physical activity, symptoms are present at rest (Won't improve during pregnancy)
Uterine rupture
Complete Incomplete Dehiscence Risk Previous uterine surgery (fibroids) Previous C-section Unscarred uterus : ⬆️ parity - thin uterine wall Blunt uterine trauma Intense ctx
Hospital care of the woman with the eclampsia
Complete bedrest Weigh daily Anticonvulsants Corticosteroids for baby Antihypertensives- to keep diastolic blood pressure between 90 and 100mmHg Diet with high protein, moderate sodium Magnesium sulfate- loading dose of 4-6g in 100 mL over 20-30 minutes Followed by 2 g/h infusion Sedative if mag sulfate does not control seizures Lungs auscultated for PE; furosemide(Lasix) given-this is a K wasting diuretics, so monitor K level Observe for renal failure Observe for signs of cerebral hemorrhage Digitalis/digoxin may be given for circulatory failure Foley catheter(strict I/O) Assessment for signs of labor Check for vaginal bleeding and abdominal rigidity Often ICU Labor may be induced Stat C-section may be necessary if baby or mom can't tolerate labor Pain relief EFM to assess fetal status Birth in Sims, semi sitting position, or lithotomy with a wedge to lessen the workload on the heart Emotional support, if baby delivered to early
DM
Complex disorder of carbohydrate metabolism caused by a partial or complete lack of insulin secretion by the beta cells of the pancreas Without insulin, glucose accumulates in the blood
A client has been diagnosed with water intoxication after having received IV oxytocin for over 24 hours. What signs and symptoms were the nurse expect to see?
Confusion, drowsiness and vomiting
hydramnios (polyhydramnios)
Congenital anomalies Idiopathic without determining cause Fetal malformations-swallowing or neurologic disorders Two types -Chronic: gradual fluid increase and problem in third trimester -Acute: fluid volume, increases rapidly over a few days
Nursing management for TOLAC
Continuous EFM IUPC IV Fluids. Avoid oxytocin, if at all possible Classic or vertical uterine incision is highest risk for uterine rupture and contraindicated Avoid prostaglandin agents
Characteristics of hypotonic contractions
Coordinated but weak Infrequent Brief intensity Can indent abdomen during peak (uterus not firm) Usually occur during active phase
S/S CHF
Cough Progressive dyspnea with exertion Orthopnea Pitting edema of legs and feet or generalized edema of face Heart palpitations Progressive fatigue or syncope with exertion Moist rales in lower lobes, indicating PE
Which of the following situation she's a nurse include as vaginal delivery emergency? A third stage of labor lasting 20 minutes B fetal heart rate dropping during contractions C three vessel cord D shoulder dystocia
D shoulder dystocia
Tocolytic therapy
Administer prior to 34th week gestation Allow time for steroid injection Allow time for maternal transfer Four types of tocolytics: -Magnesium sulfate: used to inhibit PTL by quieting uterine ctx IV loading dose, 46 g over 20 to 30 minutes Maintenance dose: 1 to 4 g/h Continue 12 hr after ctx stop or (six or less/hr) Oral tocolytic given after magnesium discontinued Assess: Urinary output minimum 30 ml/he DTRs present RR 12+/min (VS q he w/ O2 sat) Lung and heart sounds- r/o pulmonary edema and cardiac arrhythmia Bowel sounds (prior to initiation and q 4-8 hrs Serum mag levels guide maintenance Effects on fetus-decreased variability *Calcium gluconate 10%-antidote, and should be readily available -Calcium antagonist: nifedipine(Procardia) Calcium channel blocker used for HTN -Calcium essential for muscle ctx so calcium inhibitor reduces muscle ctx * side effects: flushing of the skin, h/a, transient increase in maternal and fetal HR, hypotension due to vasodilation -Prostaglandin synthesis inhibitors(indomethacin{indocin}) Prostaglandin stimulates uterine contraction Side effects: construction in Ductus arteriosus, pulmonaryHTN, oligohydramnios, nausea, heartburn, vomiting, rash, prolonged bleeding time ^ side effects unlikely if Tx no longer than 48 to 72 hours duration and <32 weeks gestation -Beta-adrenergics (terbutaline) : off label use in OB Can be given IV, PO, or SQ Initial dose SQ 0.25 mg may be repeated q 30 minutes up to 3 doses. Oral 2.5 mg to 5 mg PO every 2-4 hrs * Side effects: maternal and fetal tachycardia, decreased blood pressure, dysrhythmia, myocardial ischemia, chest pain, pulmonary edema, h/a, tremors, restlessness ^ propranolol(Inderal) used to reverse effects Nursing interventions : check apical heart rate auscultate lung sounds prior to each administration: maternal >120 or " wet" lung sounds, or SOB, suggest toxicity, and medication should be discontinued. Non-reassuring maternal or fetal assessments should be reported immediately to physician. Educate patient on side effects prior to administration
Examples of Passenger problems
Fetal size Fetal presentation or position Multifetal pregnancy Fetal anomalies
Treatment for ineffective contractions
Amniotomy Oxytocin infusion
Risks of hypotonic contractions
Maternal exhaustion Stress Postpartum hemorrhage Intrauterine infection Fetal sepsis Non-reassuring fetal status
Expected outcomes
The woman can explain Preeclampsia, eclampsia, Its implications, treatment regimen, and complications. The woman suffers, no eclamptic seizures Early detection of evidence of increasing severity or possible complications for treatment The woman gives birth to a healthy newborn
A woman has a history of placenta increta. What is the nurse understand about this condition?
There is deep placental penetration of the myometrium
Operative vaginaly birth risk
Trauma to maternal and fetal tissues
Abnormal position
Unfavorable position interferes with a dilation or descent Rotation abnormalities: -Occiput posterior OP -Occiput transverse OT Intervention goal: rotation to OA Interventions: Maternal position change -Hands and knees -Side lying -Lunges or kneeling -Squatting Birthing ball -Use with rocking motion Physician intervention -Vacuum extractor -Forceps
A nurse is monitoring a client who is receiving amnioinfusion. What assessment is critical for the nurse to make to prevent a serious complication related to the procedure?
Uterine resting tone
Uterine inversion
Uterus completely or partly turns inside out Uncommon , potentially fatal Predisposing factors : Pulling on umbilical cord prior to separation of placenta Fundal pressure during birth Fundal pressure on incompletely contracted uterus after birth Increased intra-abdominal pressure Abnormally adherent placenta Weakness of uterine wall Fundal placenta implantation
Cesarean birth contraindications
Fetal death Immature fetus Maternal coagulation defects
Direction of maternal hypotension
Position changes(often left lateral position) Increase IV infusion rate Vaginal exam to detect prolapsed cord Discontinue any IV oxytocin
Classifications of hypertension in pregnancy
Preeclampsia eclampsia Chronic hypertension -HTN before pregnancy Chronic hypertension with super imposed Preeclampsia -HDN is more severe due to pregnancy Gestational hypertension -became HTN after the 20 weeks gestation
Passenger problems: multifetal pregnancy Multiple gestation
Risks: -Uterine over distention —-hypotonic dysfunction —-abnormal presentation of one or more fetus -⬆️ for Fetal hypoxia -⬆️ for postpartum hemorrhage -C-section Physical discomforts: SOB Dyspnea on exertion Backaches & musculoskeletal disorders Pedal edema Associated problems : UTIs Threatened abortion Anemia Gestational HTN & Preeclampsia Preterm labor and birth PROM Thromboembolism Placental disorders -Placenta previa -Placental abruption Labor complications : Abnormal fetal presentations Uterine dysfunction Prolapsed cord Hemorrhage at birth or shortly after Fatal/neonatal complications Higher mortality rate than for single fetus Decreased intrauterine growth rate Increased incidence of fetal anomalies Abnormal presentations Increase in cord accidents Increase in cerebral palsy
Medical therapies for cervical insufficiency
Serial cervical u/s assessments Bedrest Progesterone supplementation Antibiotics Anti-inflammatory drugs
Cesarean preferable to operative vaginal birth with
Severe Fetal compromise Acute maternal conditions High fetal station CPD
The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal.? +1 +2 +3 +4
+3
Cervical ripening
-Effacement and softening -May be used at or near term to enhance success of, and reduce time needed for labor induction when continuing pregnancy is undesirable -May hasten beginning of labor or shorten course of labor -May cause hyperstimulation of uterus -Pharmacologic agents used for: — prostaglandins — misoprostol (Cytotec) — dinoprostone (Cervidil)
Nursing management with oxytocin
-assess FHR, frequency, duration and intensity of uterine contractions , presence of decelerations, accelerations and uterine resting tone every 15 minutes and before each increase in rate. Use Friedman's curve to make sure induction is effective -Record patient activities, procedures done and analgesics -Assess cervical dilation as needed -Continually assess for adverse maternal or fetal affects -Discontinue if adverse effects, turn woman to side, and if not reassuring fetal status, administer oxygen and notify physician
Although signs and symptoms of preeclampsia usually appear only after pregnancy has reached 20 weeks or later, preeclampsia is seen in the first trimester of pregnancy in women with
Hydatidiform mole
Reasons to induce and augment labor
Hostile intrauterine environment (HTN, DM, IUGR) SROM Post term pregnancy Chorioamnionitis Abruptio placenta (stat C-section) Maternal medication conditions that worsen with condition of the pregnancy Fetal death
Dystocia
Any difficult labor or birth
Assessment of the pregnant woman with heart disease
-assessment V/S Fatigue Signs of CHF Sudden weight gain of +2lbs in 1 day Knowledge base -Intervention Teach about increased cardiac workload — excessive weight gain and edema — exertion — exposure — emotional stress Help the family accept restrictions on activity Provide postpartum care
Vacuum extractor
-assists birth by applying section to fetal Head -Should be progressive descent with first to pulls; procedure should be limited to prevent cephalohematoma MAX THREE PULLS! MAX SHOULD NOT EXCEED 8-10 MIN Increases risk for jaundice
Stripping of the membranes
-gloved finger inserted into internal os and rotated 360° twice, separating amniotic membrane's lying against lower, uterine segment -Does not require monitoring or other assessments (often done outpatient) -May not induce labor (if labor is initiated, it typically begins within 48 hours) - May cause bleeding
Oxytocin infusion
-produces contractions, but may cause hyperstimulation of the uterus -Administered in small titrated doses -Maximum rate and dosing interval based on facility protocol, clinician order, individual situation, and maternal/fetal response -continuous fetal monitoring required -Palpating uterus essential, unless IUPC in place -may initially decrease blood pressure
S/S severe preeclampsia
Visual or cerebral disturbances Cyanosis or pulmonary edema Epigastric or RUQ pain Impaired liver function Thrombocytopenia and/or evidence of hemolysis IUGR Severe headache Scotomata Narrowed segments on retinal arterioles Retinal edema Dyspnea Moist breath sounds on auscultation Pitting edema of lower extremities N/V Irritability Emotional tension " just really feel bad"
To prevent soft tissue dystocia
Void every 1-2 hours
A woman at 26 weeks gestation is diagnosed with preeclampsia with severe features and HELLP syndrome. The nurse will assess for which of the following s/s? 1 low serum creatinine 2 high serum protein 3 bloody stools 4 epigastric pain
4 epigastric pain
A client's VS and reflexes were normal throughout pregnancy, labor, and delivery. 4 hours after delivery the client's VS are temp 98.6°F, P 72, R20, BP 150/100, and her reflexes are 4+. She has an IV infusion running with 20 units of oxytocin added to 1000 mL of lactated ringer's solution Which of the following actions by the nurse is appropriate? 1 do nothing because the results are normal 2 notify the obstetrician of the findings 3 discontinue the IV infusion immediately 4 wait and reassess the client after 15 minutes
2 notify the obstetrician because these are signs of preeclampsia
A woman at 29 weeks gestation with a diagnosis of Preeclampsia with severe features is noted to have a blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 lbs over the past 2 days. Which of the following S/S with the nurse also expect to see. 1 fundal height of 32 cm 2 oliguria 3 patellar reflexes of +2 4 nystagmus
2 oliguria
A nurse is counseling a preeclamptic client about her diet. What should she encourage the client to do?
Eat a well-balanced diet
Cesarean birth: indications
Dystocia CPD HTN Maternal diseases Active genital herpes Some previous uterine surgical procedures -Classic cesarean incision -Removal of fibroid tumors Persistent, non-reassuring FHR patterns Prolapsed, umbilical cord Fetal Malpresentations Hemorrhagic conditions
A client at 40 weeks gestation has received misoprostol for cervical ripening. The nurse would be correct in carefully monitoring for which of the following signs and symptoms? 1 diarrhea and back pain 2 hypothermia and rectal pressure 3 urinary retention and rash 4 tinnitus and respiratory distress
1 diarrhea, and back pain A common side effect of misoprostol is diarrhea. Back pain could be a sign of the start of labor, since labor contractions are often felt first in the back.
The nurse is evaluating the effectiveness of bedrest for a client with Preeclampsia without severe features. Which of the following S/S would the nurse determine is a finding that suggests preeclampsia with severe features? 1 platelet count 95,000 2 2+ proteinuria 3 increase in plasma proteins 4 serum creatinine greater than 1.3 mg/dL.
1 platelet count 95,000 2 2+ proteinuria 4 serum creatinine greater than 1.3 mg/dL.
A client at 32 weeks gestation was last seen in the prenatal clinic 4 weeks ago at 28 weeks gestation. Which of the following changes should the nurse bring to the attention of the certified nurse midwife? 1 weight change from 128 pounds to 138 pounds 2 pulse rate change from 88 BPM to 92 BPM 3 blood pressure change from 120/80 to 118/78 4 respiratory change from 16 to 20
1 weight change from 128 pounds to 138 pounds
Risks of tachysystolic labor patterns
Increased discomfort Fatigue Stress Dehydration Increased risk of infection Placental abruption Non-reassuring fetal status Prolonged pressure on fetal head
Cesarean birth, maternal risks
Infection Hemorrhage Urinary track trauma or UTI Thrombophlebitis, thromboembolism Paralytic ileus Atelectasis Anesthesia complications
A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values.: PT 99 seconds (normal=60-85) PTT 30 seconds (normal=11-15) For which of the following signs and symptoms with the nurse monitor the client ? A pink tinged urine B early decelerations C patellar reflexes +1 D blood pressure 140/90
A pink tinged urine
The nurse notes a pattern of tachysystole during a clients oxytocin induction. The nurse turns off the oxytocin infusion. Which of the following outcomes indicates that the nurses action was effective. 1 contraction intensity moderate 2 contraction frequency every 3 minutes 3 fetal heart rate 140 BPM 4 fetal attitude flexed
2 contraction frequency every three minutes
A pregnant woman with a Obesity is being seen in the prenatal clinic. The nurse will monitor this client carefully throughout her pregnancy because she is at high risk for which of the following complications of pregnancy? 1 placenta previa 2 gestational diabetes 3 deep vein thrombosis 4 Preeclampsia 5 chromosomal defects
2 gestational diabetes 3 deep vein thrombosis 4 Preeclampsia
An oxytocin induction of a client at 42 weeks gestation is started at 0900 at a rate of 2 milliunits/min. The clients primary physician orders an increase of the oxytocin drip by 0.5 Milliunits/minute every 10 minutes until contractions are every 3 minutes X 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurses action? 1 fetal intolerance of labor has been noted when oxytocin dosage greater than 2 milliunits/minute are administered 2 the relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug as ordered 3 it is unsafe practice to administer oxytocin intravenously to a client who is carrying a postdates fetus 4 a contraction duration of 60 seconds, can lead to fetal compromise in a baby that is post mature
2 the relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug as ordered. The standard of care is to increase the dosage of oxytocin at a minimum time interval of every 30 minutes, not every 10 minutes
Intrapartum management for multiple gestation
Insertion of large-bore IV in mother Anesthesia and cross matched blood readily available Continuous dual EFM of twins Method of birth might not be decided until labor begins C-section birth may be indicated
Which of the following lab values should the nurse report to the physician as being consistent with a diagnosis of HELLP syndrome? 1. Hematocrit 48% 2. Potassium 5.5 mEq/L 3. Platelets 75,000 4. Sodium 130 mEq/L
3 platelets 75,000
A client is seen at eight weeks gestation for her first prenatal visit. During her last gynecological visit, the clients blood pressure was 100/60. Her blood pressure is now 150/90. For which of the following pregnancy related illnesses should this client be assessed? 1 hyperemesis gravidarum 2 hydatidiform mole 3 Preeclampsia 4 gestational diabetes
3 preeclampsia
A patient has an order for prostaglandin E preparation. What does the nurse understand about this medication?
It is a cervical ripening agent
Nursing actions for hypertonic uterine activity
Reduce or stop oxytocin infusion Increase rate of primary non-additive infusion Keep laboring woman in lateral position Give oxygen snug facemask 8 to 10 L/min Notify physician
Mechanical dilation with intra-cervical catheter
30 mL Foley bulb or double balloon to put pressure Does not increase incidence of infection, and without causing fetal tachysystole Disadvantage is difficulty and placement and failure to maintain placement, Limited ambulation May shorten first stage of labor
Intrapartum management of cardiac disease
300 to 500 mL of blood is shifted from the uterus and placenta into central circulation -Extra fluid causes a sharp rise in cardiac workload Vaginal delivery is recommended for a woman with heart disease, unless there are specific indications for cesarean birth Minimize maternal pushing and use of the Valsalva maneuver (drops BP) Limit prolonged labor
The perinatal nurse is aware that recommendations for elective deliveries specify induction no earlier than what gestational age?
39 weeks
A client has Preeclampsia with severe features. The nurse would expect the primary healthcare provider to order tests to assess the fetus for which of the following? 1 severe anemia 2 hypoprothrombinemia 3 craniosynostosis 4 IUGR
4 IUGR
In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches a client at 18 weeks gestation to call the office if she experiences which of the following? A headache and decreased output B puffy feet C hemorrhoids, and vaginal discharge D backache
A headache and decreased output
The perinatal nurse is aware that complications arising from amnioinfusion include which of the following? A infection B halt in labor C neonatal hydrocephalus D fluid overload
A infection
Preterm labor
> 20 weeks but <38 weeks 1:8 births are preterm Maternal risk : Infection Hemorrhage Need for a C-section Psychological stress Infant risk : Ill-equipped for extrauterine life -Respiratory distress -Birth trauma Associated factors : often unknown Maternal medical conditions : Infection (urinary, reproductive, or systemic organs) Periodontal disorders GDM Connective tissue disorders Chronic HTN Drug abuse Conceptions achieved by assisted reproduction
Which of the following statements apply to Preeclampsia A Fetal risks include still birth, IUGR, and placental abruption B platelet count below 200,000 C blood pressure above 140 mmHg, systolic and or 90 mmHg diastolic D can be treated and cured with antihypertensives if caught early enough E magnesium sulfate to reduce seizure activity F risks include pulmonary edema, congestive heart failure, hepatic failure, and cerebral hemorrhage G requires immediate cesarean delivery H fetal macrosomia may occur
A C E F
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal position should the nurse suggest to the client to facilitate normal labor progress? A hands and knees B lithotomy C Trendelenburg D supine with a rolled towel under one hip
A hands and knees
A nurse is caring for a client who is 42 weeks gestation having an ultrasound. For which of the following condition, should the nurse plan for an amnioinfusion? SATA A oligohydramnios B hydramnios C fetal cord compression D hydration E Fetal immaturity
A oligohydramnios C fetal cord compression
S/s hypoglycemia
Diaphoresis Shakiness Sleepiness Irritability " cold and clammy give them candy"
Factors associated with Precipitate labor
Abruptio placenta Fetal meconium Maternal cocaine use Postpartum hemorrhage ⬇️ Apgar score of infant
Who is at greater risk for uterine rupture?
Anyone who has had a previous cesarean section
Care during seizures
Bed low and locked Call light in reach Bed rails up and padded As close as possible to nurses' station Open door
Heart disease, pre-existing conditions
CHD HTN CAD Myocarditis Mitral valve prolapse DM (vascular problems)
A nurse administers magnesium sulfate via infusion pump to a laboring client who has preeclampsia with severe features. Which of the following outcomes indicates that the medication is effective. A client has no patellar reflex response B urinary output is 30 mL/hr C respiratory rate is 16 rpm D client has no grand mal seizures
D client has no grand mal seizures
Perinatal Fetal loss
Death of a fetus or infant between conception in the 28 days after birth Intrauterine fetal demise IUFD Organize and coordinate a team approach to bereavement What to say?
Therapeutic management of preterm labor
Early identification of those at risk -Treat intensively -Does not at risk, but have symptoms, treat regular prenatal care Predictive factors : Short cervical length <25mm Previous preterm birth Positive FFN after 22 weeks -FFN protien found in fetal tissue -Normal cervical secretion present up to 16 to 20 weeks and again near term -False positive may occur if done after cervical exam, recent intercourse, or if vaginal bleeding present
Blood sugar during pregnancy
Early may be normal or decreased because of increase insulin production and tissue sensitivity Middle to late pregnancy increased because of maternal insulin resistance
Cervical insufficiency
Formerly called incompetent cervix Painless, dilation of the cervix without ctx due to a structural or functional defect of the cervix Risk factors : -Acquired factors Inflammation or infection Cervical trauma Cone biopsy Late second trimester elective abortion Hemorrhage Increased uterine volume due to multiple gestations Previous preterm birth -Structural defects Diethylstilbestrol (DES) exposure Bicornuate uterus Collagen disorder
Why does GDM cause vascular changes?
Glucose gets deposited on vessel lumens just like lipids which can = HTN (risk factor for preeclampsia)
Post term pregnancy— maternal risks
Labor induction LGA infant and perineal trauma Forceps assisted, vacuum assisted, or cesarean birth Increased psychologic stress Increased risk for infection
Cesarean birth technique
Preparation: Anesthesia Medication Lab studies Prophylactic antibiotics Skin prep Foley catheter Incision: Low transverse Low vertical Classical
The perinatal nurse knows that which condition must be met before assisting at a forceps delivery
Presenting part must be engaged
AROM
Risks: prolapsed cord Infection Abruptio placenta Must be least 2 cm dilated and Head at least engaged (r/o cord, prolapse or placenta abruptio) FHR prior to procedure Place underpads beneath buttocks Post procedure: IMMEDIATELY assess FHR for a full minute Chart quantity, color, odor of fluid PRIORITY: Must assess maternal temp every 2 hours (r/o infection) Keep perineum clean and dry
A client is on magnesium sulfate for preeclampsia with severe features. The nurse must notify the attending physician regarding
Serum magnesium level of 10 mg/dL
Things that affect blood sugar
Stress Exercise Diet Steroids Infection
Gravid client with 4+ proteinuria and 4+ reflexes is admitted to the hospital. The nurse most closely monitor the woman for which of the following? 1 grand mal seizure 2 high platelet count 3 explosive diarrhea 4 jaundice
1 grand mal seizure
DM: fetal surveillance
Surveillance should begin early for women with pre-existing diabetes Testing for anomalies Frequent u/s Fetal echocardiogram Fetal kick count
A client at 24 weeks gestation is being seen in the prenatal clinic. She states "I have had a terrible headache for the past two days". What is the most appropriate action for the nurse to perform next.
Take the clients blood pressure
Nursing management of tachysystolic labor
Assess contractions, vitals, and FHR Provide comfort and support measures Change positions (every 30min-1hour) Provide therapeutic touch Visualization Warm showers or bath Sedation, pain medication Client education
Hypertrophic cardiomyopathy
Heart muscle a stick and making it hard for the heart pump blood; Often asymptomatic A possible fetal effect of maternal pre-existing DM
Patients with mitral valve prolapse
Are the MVPs
The nurse hears a healthcare provider, describe a pregnant woman as having tocophobia. What does the nurse understand this to mean?
Fear of childbirth
Risks with induction and augmentation of labor
Hypertonic uterine activity Uterine rupture Maternal water intoxication Greater risk for chorioamnionitis Greater risk for C-section
S/s of GDM
Polydipsia Polyuria Polyphagia Fatigue Nausea Sugar in urine Frequent bladder infections skin infections because of dry skin Yeast infections Blurred vision Dry mouth
Perinatal nurse uses the acronym SPASMS to teach a new nurse about preeclampsia. What does the P refer to?
Proteinuria
Third and fourth stage complications
Retained placenta Lacerations Placenta accreta
Therapeutic management of DM
Maintain normal blood glucose levels: euglycemic Facilitate the birth of a healthy baby Avoid accelerated impairment of blood vessels and other major organs Preconception care (control glucose before pregnancy) Diet Self monitoring of glucose Insulin therapy Educate them on the importance of keeping appointments
Conditions prone to ineffective contractions
Maternal fatigue Maternal inactivity Fluid/electrolyte imbalance Hypoglycemia Excessive analgesia/anesthesia Maternal catecholamines (stress response) Fetal pelvic disproportion Uterine overdistention (multiples or hydramnios)
The physician has ordered dinoprostone for 4 clients at term. The nurse should question the order for which of the women? 1 Primigravida with a bishop score 4 2 multigravida with late decelerations 3 Primigravida with fetal heart rate of 155 and Bishop score 4 4 G6 P3202 with blood pressure 140/90 and pulse 92
2 multigravida with late decelerations
Problems associated with precipitate birth
Maternal: Uterine rupture Cervical laceration Hematoma of vagina or labia Fetal: Direct trauma -intracranial hemorrhage or nerve damage Hypoxia -increase intensity of contraction, decreased uterine, relaxation, and gas exchange in placenta)
A nurse is administering magnesium sulfate, IV for seizure prophylaxis to a client who has severe preeclampsia. Which of the following indicates magnesium sulfate toxicity? Select all that apply. A. R<12/min B. Urinary output <25ml/hr C. Hyperreflex deep-tendon reflexes. D. Decreased LOC E. Flushing and sweating.
A R<12/min B urinary output <25ml/hr D decreased LOC
A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurses. Which of the following statements by a nurse indicates an understanding of the teaching.? A they are tablets administered vaginally B they act by absorbing fluid from tissues C they promote dilation of the os D they include amniotomy
A they are tablets administered vaginally
A client at 38 weeks gestation with hypertension and oligohydramnios is being induced with IV oxytocin. She is contracting q3 minutes x 60-90 seconds. She suddenly complains of abdominal pain. The nurse notices significant fetal heart rate bradycardia. Which of the following intervention should the nurse perform first? A turn off the oxytocin infusion B administer oxygen via facemask C reposition the patient D call the obstetrician
A turn off the oxytocin infusion
In which of the following situations would amnioinfusion be appropriate? A placental abruption B meconium stained fluid C polyhydramnios D late decelerations
B meconium stained fluid
Preeclampsia (ATI definition)
GH with the addition of protein urea of greater than or equal to 1+. Report of transient headaches might occur along with episodes of irritability. Edema can be present.
Which of the following physical findings would lead the nurse to suspect that a client who has preeclampsia with severe features has developed HELLP syndrome? Select all that apply. 1. 3+ pitting edema 2. Petechiae. 3. Jaundice 4. 4+ deep tendon reflexes. 5. Elevated specific gravity.
Petechiae Jaundice
Ineffective Maternal Pushing
-urge to push occurs during second stage of labor as presenting part reaches pelvic floor -Ineffective pushing occurs: Incorrect technique or inefficient position Fear of injury Decrease urge Maternal exhaustion Regional anesthesia Psychological unreadiness -Management: correct cause Not time sensitive if maternal and fetal VS normal Positioning(squatting, semi sitting, side lying) epidural can restrict positioning Fear of injury(provide information) Maternal exhaustion(encourage rest, intermittent pushing, oral or IV fluid) Keep bladder empty (void every 2hours)
Which of the following clients is at highest risk for developing a hypertensive illness of pregnancy? 1 G1 P0000 age 41 with history of diabetes mellitus 2 G2 P0101 age 34 with history of rheumatic fever 3 G3 P1102 age 27 with history of scoliosis 4 G3 P1011, age 20 with history of celiac disease
1 G1 P0000 age 41 with history of diabetes mellitus
The primary healthcare provider has ordered oxytocin for induction for 4 clients, in which of the following situations where the nurse refused to comply with the order? 1 primigravida with a transverse lie 2 multigravida with cerebral palsy 3 Primigravida who is 14 years old 4 multigravida, who has type 1 diabetes mellitus
1 Primigravida with a transverse lie
A nurse remarks to a client who has come to the clinic at 38 weeks gestation. "It looks like your face and hands are swollen." the client responds "yes you're right, why does it matter? " The nurse's response is based on the fact that the changes may be caused by which of the following? 1 altered glomerular filtration 2 cardiac failure 3 hepatic insufficiency 4 altered splenic circulation
1 altered glomerular filtration
A full term client contracting every 15 minutes X 30 seconds has had rupture of membranes for 20 hours. Which of the following nursing interventions is contraindicated, or considered high risk at this time? 1 intermittent fetal heart auscultation 2 vaginal examination 3 intravenous fluid administration 4 nipple stimulation
1 intermittent fetal heart auscultation 2 vaginal examination
Patient is being stabilized in the labor suite following a diagnosis of eclampsia. The fetal heart rate tracing shows moderate variability with intermittent late decelerations. Which of the following actions by the nurse is appropriate at this time? A tape a tongue blade to the head of the bed B pad the side rails and head of the bed C provide the client with needed stimulation D provide the client with grief counseling
B pad the side rails and head of the bed
The nurse observes a new staff member caring for an eclamptic client following a seizure. Which of the following actions by the staff member indicates an understanding of eclampsia? A check each urine for presence of key tones B pad the client's bed rails and headboard C provide visual and auditory stimulation D play the bed and high Fowlers position
B pad, the clients bed rails and headboard
Postpartum management of cardiac disease
Although no evidence of distress during pregnancy, labor, and childbirth, women may have cardiac decompensation during the postpartum period -Blood from the placenta and uterus increases the work load of the heart Close observation for signs of infection, hemorrhage, and thromboembolism -Conditions can act together to precipitate postpartum heart failure
anaphylactoid syndrome Amniotic fluid embolism AFE
Amniotic fluid enters maternal circulation, and enters lungs Fetal particulate matter obstructs pulmonary vessels Abrupt respiratory distress , depressed cardiac function, and circulatory collapse Development of DIC is likely Often fatal Therapeutic management : Rapid intervention CPR and support Oxygen with mechanical ventilation Correction of hypotension Blood component therapy (fibrinogen, PRBC, platelets, FFP) If maternal cardiac arrest -immediate C-section to improve survival odds for baby
Postpartum care of the woman who delivers macrosomia infant
Anticipate excessive uterine stretching Expect uterine atony and boggy uterus Monitor for and treat uterine hemorrhage -fundal massage -IV or IM oxytocin may be needed Closely monitor maternal VS for development of shock
Clients previous clinic assessment at 32 weeks was BP 90/60, temp 98.6°F, P 92, R 20, weight 145 lbs, and urine negative for protein. Which of the following findings at 34 weeks gestation should the nurse highlight for the certified nurse midwife ? A BP 110/70, temp 99.2°F, P 88, R20. B weight 155lbs, urine protein +2 C urine protein trace, BP 88/56 D weight 147 lbs , temp 99°F, P 76, R 18
B weight 155 pounds, urine protein +2
Nursing care for severe Preeclampsia
Assess: BP q 15-30 minutes Temperature Pulse and respirations FHR Hourly urinary output Protein specific gravity Weight PE DTRs Laboratory blood tests (urinalysis, CBC, 24 hour urine, liver function study, dig toxicity test, if on digitalis/digoxin) LOC Emotional response Level of understanding Access for Placental separation (EFM) h/a Visual disturbances Epigastric pain Maintain a quiet, low stimulus environment : private room with limited visitors Woman should be in left lateral recumbent position Limit phone calls, bright lights, sudden noises Monitor effectiveness of medications Provide care during seizures
Discovery of unexpected cervical dilation
Attempt may be made to rescue pregnancy through cerclage placement after advanced cervical dilation May require decompression of bulging amniotic sac -Preoperative evaluation for infection, ruptured membranes, and uterine activity may be prudent Perioperative an ongoing treatment -tocolytics (drugs that stop labor) -Broad-spectrum antibiotics -Anti-inflammatory agents
External version
Attempted >36 weeks prior to onset of labor NST to evaluate fetal well-being -Contra indications — maternal Uterine malformations Previous C-section with vertical uterine incision Disproportion between fetal size and pelvic size — fetal Placenta previa Multi fetal gestation Oligohydramnios Uteroplacental insufficiency R/O Cord entanglement Abruptio placenta Mixing of maternal fetal blood Cesarean birth for fetal compromise Administer tocolytics (terbutaline, 0.25 mg SQ to reduce uterine contractions U/S guided Fetal manipulation RhoGAM administered to Rh- mothers after procedure Labor induction may begin immediately after successful version or can wait for spontaneous labor Observe for 1hr post procedure, if labor postponed Should only be performed when there is the ability to provide a cesarean delivery if necessary
A pregnant woman with a Obesity is being seen in the prenatal clinic. The nurse will monitor this client carefully throughout her pregnancy because she is at high risk for which of the following complications of pregnancy?SATA A placenta previa B gestational diabetes C deep vein thrombosis D Preeclampsia E chromosomal defect
B C D
A nurse is caring for a client in active labor. When last examined 2 hours ago, the clients cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at -2 station. The client suddenly states." my water broke." the monitor reveals and FHR of 80 to 85./min and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the clients vagina. Which of the following action should the nurse perform first? A place the client in the Trendelenburg position B apply pressure to the presenting part with the fingers C administer oxygen at 10L/minute via facemask D initiate IV fluids
B apply pressure to the presenting part with the fingers
A nurse is monitoring the labor of a client who is receiving IV oxytocin at 10 milliunits per minute. Which of the following clinical signs would lead the nurse to stop the infusion.? A change in maternal pulse rate from 76 to 98 BPM B change in fetal heart rate from 128 to 102 BPM C maternal blood pressure of 150/100 D maternal temperature of 102.4°F.
B change in fetal heart rate from 128 to 102 BPM The baseline fetal heart rate is below the normal rate of 110 to 160. This find warrants that the oxytocin be stopped.
A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC), placed to monitor uterine contractions. For which of the following contraction patterns, should the nurse discontinued the infusion of? A frequency of every 2 minutes B duration of 90 to 120 seconds C intensity of 60 to 90 mmHg D resting tone of 15 mmHg
B duration of 90 to 120 seconds
A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 120 BPM with moderate variability. Which assessment is most important for the nurse to make at this time. A contraction frequency and duration B maternal temperature C cervical dilation and effacement D percuss the clients uterus and monitor for ballottement
B maternal temperature
A client with a BMI of 31.2 as seen for her first prenatal visit at 7 weeks gestation period. The nurse requests in order from the primary healthcare provider for which of the following tests? A electroencephalogram B oral glucose tolerance test C biophysical profile D lecithin/sphingomyelin ratio
B oral glucose tolerance test
A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A precipitous labor B premature rupture of membranes C postmaturity syndrome D prolapsed umbilical cord
D prolapsed umbilical cord
Severe preeclampsia diagnostic criteria
May develop suddenly BP >160/>110 on 2 occasions at least 6 hours apart during bedrest Proteinuria >5 g/L in 24 hour urine collection +3 or more protein dip stick on 2 random samples at least 4 hours apart Oliguria with your an < 500 mL in 24 hours Urine will be dark and concentrated (high specific gravity)
Hospital care for preeclampsia
Bedrest, primarily left side Weigh daily-notify physician of more than 2 lb gain/day Evaluate for edema, h/a, visual changes, epigastric pain Urine dipstick daily BP 4 times/day Balanced diet, moderate to high protein, low sodium Labs assessed daily and PRN
Clinical therapy for post term pregnancy
Biweekly assessments of fetal well-being -NST, BPP, modified BPP, or CST Teach the woman to perform daily assessment of fetal movement
Determining ROM
Body fluids (urine, vaginal discharge, or mucous plug can be mistaken for ROM) Speculum exam -Check fluid pooling and estimate dilation and effacement pH test (nitrazine) Assess for ferning Amnisure
A nurse notes that a pregnant patient has 3+ reflexes noted on her chart. How would the nurse describe this finding to a nursing student?
Brisker than average
Newborn risks of operative vaginal birth
Bruising Edema Facial lacerations Cephalohematoma Transient facial paralysis Cerebral hemorrhage
The nurse has assessed 4 primigravida clients in the prenatal clinic. Which of the following women would the nurse refer to the nurse midwife for further assessment? A 10 weeks gestation, complains of fatigue with nausea and vomiting B 26 weeks, gestation, complains of ankle edema and chloasma C 32 weeks gestation complains of epigastric pain and facial edema D 38 weeks gestation complains of bleeding gums and urinary frequency
C 32 weeks gestation complains of epigastric pain and facial edema
Which of the following statements apply To GDM A Diet and exercise make no impact B Increased risk of hyperglycemia for both the mother an infant at delivery C Puts infant at risk for macrosomia and other complications D Insulin resistance in pregnancy is a normal finding E Risks can include the development of Preeclampsia, the need for a cesarean section, and postpartum hemorrhage F Family history and polycystic ovarian syndrome are risk factors G Postprandial glucose levels should be below 150 mg/dL H Diagnosis is based on testing between 24 and 28 weeks
C D F H
A nurse is caring for a client who had no prenatal care is Rh negative, and will undergo an external version at 38 weeks of gestation. which of the following medication should the nurse plan to administer prior to the version? A prostaglandin gel B magnesium sulfate C Rho(D) immune globulin D oxytocin
C Rho(D) immune globulin
A 35-year-old client with preeclampsia is being induced with oxytocin. She is contracting every 3 minutes with each contraction lasting 30 seconds. Suddenly the client becomes dyspneic and cyanotic and begins to have chills which of the following nursing interventions is of highest priority. A check blood pressure B assess fetal heart rate C administer oxygen D stop the oxytocin infusion
C administer oxygen
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? A intrauterine growth restriction B hyperglycemia C meconium aspiration D polyhydramnios
C meconium aspiration
A client with an obstetrical history of G3, P1010, is receiving oxytocin via IV pump at 3 milliunits/minute. Her current contraction pattern is every 3 minutes X 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 BPM with moderate variability. which of the following interventions should the nurse take at this time?' A stop the infusion B give oxygen via facemask C change the clients position D monitor the clients labor
D monitor the clients labor
4 women request to labor in the hospital bathtub with waterproof fetal heart rate monitoring devices. In which of the following situations is this contraindicated? SATA A client during transition B client during second stage of labor C client receiving oxytocin for induction D client with meconium stained fluid E client with a temperature of 100.4°F.
D client with meconium stained fluid E client with a temperature of 100.4°F.
A client with an obstetrical history of G4 P1021 has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, FHR of 150 with moderate variability and no decelerations Temp 98.6°F. , P 88, R 20, BP 120/80, negative obstetric history. Dinoprostone has been inserted Which of the following findings would warrant the removal of the prostaglandin? A Bishop score of 4 B fetal heart rate of 155 C respiratory rate of 24 D contraction frequency of 1 minute
D contraction frequency of 1 minute
The nurse notes that the fetus of a laboring client is exhibiting signs of fetal intolerance of labor. Which of the following action should the nurse take? A administer oxygen via nasal cannula B place the client in high Fowlers position C remove the internal fetal monitor electrode D increase the intravenous infusion rate
D increase the intravenous infusion rate
Risks associated with GDM
Macrosomia (cephalohematoma, dystocia, brachioplexus, facial nerve) RDS Hyperbilirubinemia Aged placenta Fetal demise
The perinatal nurse understands that one of the risks of oxytocin infusion includes FHR changes related to:
Decreased placental perfusion
Post term pregnancy —fetal risks
Decreased placental perfusion Oligohydramnios Meconium aspiration Low five minute Apgar score Birth trauma Uteroplacental insufficiency Loses, subcutaneous fat and muscle mass (dysmaturity syndrome)
Manifestations of uterine rupture
Dehiscence No symptoms initially Interrupted labor progress Larger area persistent pain, despite analgesic Incomplete Slow blood loss delayed symptoms Complete Massive blood loss /symptoms develop quickly Manifestations vary with degree of rupture -abd pain/tenderness -Sudden onset (ripped/gave way) -Chest pain/pain between scapula/pain inspiration -Hypovolemic shock -Impaired fetal oxygenation(late decels, variables, etc) -Cessation of uterine ctx
Passenger problem: shoulder dystocia
Delayed or difficult birth due to shoulders being impacted above symphysis bone -Signs: Turtle sign (head retracts into perineum) Failure of shoulders to complete external rotation -Unpredictable -Requires immediate intervention MCROBERTS MANEUVER
Management of PPROM
Dependent on gestation and evidence of infection -If less than 37 weeks with absence of infection, treatment is conservative -Earlier than 34 Weeks, weigh risk for infection or preterm birth against hazards of actively promoting birth Determine duration of the rupture of membranes Assess gestational age Assess FHR Monitor for infection Evaluate the woman and partner's childbirth preparation and coping abilities Assess uterine activity and Fetal response to the labor -Vaginal exams only if necessary
Therapeutic management of GDM
Diet -Registered dietitian, register dietary technician, or diabetes educator -Nonobese prepregnancy weight, an average of 30 kcal/kg/day is recommended Exercise Blood glucose monitoring Fetal surveillance -NST, at Home kick count, may need u/s
Maternal education needs for multiple gestation
Dietary counseling: -Prenatal vitamins -Daily intake of 3500 kcal minimum and 175g protein for normal- weight twins -Daily intake of 1 mg of Folic acid -Recommended total weight gain of 40-45 lbs with a 24lb gain by 24 weeks Activity counseling: -Frequent rest periods —-side lying position with lower legs and feet elevated -Relief of back discomfort —-pelvic rocking —-good posture —-pregnancy belt —-good body mechanics
A client is admitted to the hospital with a diagnosis a Preeclampsia with severe features. How does the nurse check for Clonus?
Dorsiflex the foot quickly and watch for bouncing
Therapeutic management of cardiac disease
Drug therapy Anticoagulants Antidysrhythmics Anti-infectiveS Drugs for heart failure Pregnancy complicates the use of some of these drugs
Multiple gestation post delivery care
Duplicate all necessary supplies Additional staff members should be available Special precautions to insure correct identification of newborns
A client with preeclampsia with severe features at 38 weeks gestation is being induced with IV oxytocin. What would warrant the nurse to stop the infusion?
Duration of contractions of 130 seconds
S/S heart disease
Dyspnea Syncope with exertion Hemoptysis Paroxysmal nocturnal dyspnea Chest pain with exertion The severity of the disease is determined by ability to endure physical activity
Manifestation of preterm labor
Early phase: subtle vague Active phase : Uterine contractions (painful or painless) -Frequent "balling up" of baby -Menstrual cramping Low back ache Pelvic pressure or pain Change in vaginal discharge Abd cramping with or without diarrhea " just don't feel right" Prevention : education -Early and regular prenatal care -Duration of normal pregnancy -Risk factors -Signs and symptoms -Consequences for mom and baby
A client at 40 weeks gestation has an admitting platelet count of 90,000 and a Hematocrit of 29%. Her lab values 1 week earlier were platelets 200,000 and hematocrit 37%. What additional lab value does the nurse expect to see?
Elevated alanine aminotransaminase (ALT)
Management of prolapsed umbilical cord
Emergent intervention -Relieve pressure to restore blood flow -Stay with patient Actions -Position hips higher than head-elevate, presenting part off cord —-knee chest position —-Trendelenburg —-hips elevated with pillows -If hip elevation, ineffective: vaginal elevation using sterile gloved hand —-maintain until physician orders are just before C-section delivery -Avoid handling cord -u/s to confirm FHT prior to C-section -02 at 8 to 10 L/min/mask (increase maternal O2 saturation) -May use SQ tocolytic (terbutaline) -Apply warm saline moist towels to exposed cord Prognosis : Maternal good Infant dependent on how long and how severe interrupted blood flow
Characteristics of hypertonic contractions
Erratic and uncoordinated Can be painful yet ineffective Usually occur during latent phase ⬆️ uterine resting tone = ⬇️ uterine blood flow= ⬇️ fetal O2 supply Constant cramping Late Decels
A nurse is caring for a client who has been in labor for 12 hours with intact membranes. The nurse performs a vaginal examination to ensure this prior to the performance of the amniotomy
Fetal engagement
A nurse is reviewing hypotonic labor with a student nurse. The nurse explains to the student that the most common cause of this dysfunctional labor pattern is:
Fetal macrosomia
passenger problems (abnormal presentations)
Fetal presentation or position -occiput is normally the presenting part -Fetal malpresentations Brow, face, breech, shoulder(transverse lie), compound presentation * Internal scalp electrode contraindicated with face or chin presentation Abnormal presentation -Deflexion anomalies-results poorly flexed head (face presentation) -breech presentation 4% occurrence at term-exact cause unknown Maternal implication is the likelihood of cesarean birth Fetal implication is higher, perinatal, morbidity and mortality rates, increased risk of prolapsed cord, increased risk of cervical cord injury, caused by hyper extension, increased risk of asphyxia and non-reassuring fetal status, increased risk of birth trauma #Delivery options-majority of infants in breech presentation is born by cesarean Common features of women who have breech vaginal birth: multiparous women, proven pelvis, active labor, unknown, breech presentation. Nursing role during breech delivery: Vaginal: include Piper forceps in birth table set up Nurse may assist physician if forceps are needed for the birth Cesarean: nurse assess as with any cesarean birth "Double set up" (frank or footling) Complications: fetal injury, prolapsed cord, hydrocephalus, complications secondary to placenta previa ECV may be attempted -Shoulder presentation (transverse lie) Clinical management depends on gestational age If discovered before term, management is expectant (watchful) If still evident at 37 completed weeks of gestation, ECV attempt followed by induction of labor if successful Maternal Nursing care-Identify transverse lie — inspection, and palpation of abd — auscultation of FHR — vaginal examination Assist in interpretation of fetal presentation Provide information and support to the couple Frequent assessment of maternal and fetal status Prepare the woman for cesarean birth -Compound presentation 2 presenting parts: most compound presentations resolve spontaneously, but others require additional manipulation at birth and
During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. What action should the nurse perform?
Flex the client's thighs sharply towards her abdomen for McRoberts maneuver
McRoberts maneuver
Flexing the woman's knees toward her shoulders to free the baby's shoulder from the maternal pubic bone
Possible nursing diagnosis for mild to severe preeclampsia
Fluid volume deficit r/t fluid shift from intravascular to extravascular space secondary to vasospasm Risk for injury r/t possibility of seizure, secondary to cerebral vasospasm or edema Risk for aspiration Risk for stroke Risk for anxiety
Stopping preterm labor
Focus placed on stopping uterine activity before point of no return >3cm -steroid therapy, promotes early lung maturity -Everyone day of fetal lung maturity improves outcome for premature infant Initial measures : -Determine maternal or fetal conditions, contraindicating continuing pregnancy — Preeclampsia, eclampsia, chronic HTN — prolonged maternal alterations: hypovolemia, hypoxemia, acid base imbalance — serious infections: chorioamnionitis or maternal pyelonephritis — non-reassuring NST -Identify and treat infection -Identify treatable causes -Decreased activity -Hydrate
Operative birth
May be necessary, if dysfunctional labor not resolved or if maternal or fetal complications occur -Use a vacuum extractor -Use of forceps -C-section Signs of necessity -Persistent non-reassuring FHR pattern -Fetal acidosis -Meconium passage -Maternal exhaustion -Infection
Clinical therapy for multiple gestation
Frequent prenatal visits Maternal education : -nutritional implications -Assessment of fetal activity -Signs of preterm labor -Danger signs of pregnancy Serial U/Ss to monitor fetal growth -twin to twin transfusion syndrome Third trimester testing -Usually begins at 32 to 34 weeks -May include NST or BPP
GDM screening
Glucose challenge test done at 24 to 28 weeks -One hour test-no prep/no fasting-50g oral glucose solution -Yes above 140 mg/dL, then 3 hour OGTT of 100 g glucose solution ordered OGTT Fasting > 95 mg/dL 1 hour > 180 mg/dL 2 hour > 155 mg/dL 3 hour > 140 mg/dL * if two or more values are elevated, GDM diagnosis is made
Cardiac disease
Heart disease complicates about 1% of pregnancies It remains a significant cause of maternal mortality
Nursing care for a Preeclampsia eclampsia
Help couples identify their concerns -Women May fear losing her fetus, worry about relationships, be concerned about finances, feel bored and resentful about bedrest -May have trouble caring for other children offer information Refer to support groups and home services
Risks of TOLAC/VBAC
Hemorrhage Infection Uterine rupture Infant death or neurologic complications Operative injuries Thromboembolism Hysterectomy Death
Maternal assessment for DM
History -Onset and management of diabetic condition -May need insulin to control Physical exam -Baseline ECG -Ophthalmology referral -Height, weight and BP Lab tests -24 hour urine -Hemoglobin A1c
Maternal risks with GDM
Hydramnios Preeclampsia - eclampsia Ketoacidosis Retinopathy Increased susceptibility to infection
Neonatal risks because of GDM
Hypoglycemia Hypocalcemia Hyperbilirubinemia RDS (hormones of pregnancy +insulin/glucose lowers surfactant production— don't cold stress this baby)
A client at 32 weeks gestation with a severe headache and ankle swelling is admitted to the hospital with preeclampsia. Her VS are as follows temp 98.6°F, P 100, R 20, BP 160/112 BP was repeated in 15 minutes and was 140/70. Which of the anticipated providers orders can a nurse consider to be indicated, nonessential, or contraindicated ?
INDICATED Magnesium sulfate 4 g bolus over 20 minutes, followed by maintenance infusion of 2 g/hr per IV pump Continuous fetal monitoring Corticosteroids Begin 24 hour urine collection for protein Antihypertensive medication NONESSENTIAL insert indwelling catheter and send urine specimen to lab CONTRAINDICATED Begin oxytocin induction
Management of ineffective contractions
IV or oral fluids Correct fluid/electrolyte imbalance Correct hypoglycemia Position change(walking, upright position promotes descent) Pain management(epidural can reduce contraction effectiveness)
A client has just been diagnosed with gestational diabetes. She states " oh no! I will never be able to get myself shots!" which response by the nurse is appropriate at this time
If you follow your diet and exercise, you will probably need no insulin
Other causes of heart disease
Illicit drug use Alcohol abuse Familial heart disease of pregnancy Peripartum cardiomyopathy -a rare dysfunction of the left ventricle that occurs in the last month of pregnancy or within 5 months postpartum
Treatment of non-reassuring fetal status
Immediate intrauterine resuscitation Improve fetal blood flow -Correct maternal hypotension -Decrease intensity, and intensity of ctx if present -Administer maternal IV fluids as needed Administer 02 Gather more information about fetal status -Fetal scalp stimulation -Fetal acoustic stimulation
Nursing considerations for GDM
Increase effective communication Provide opportunities for control Provide normal pregnancy care
A nurse reads in a woman's chart that she has a history of dystocia. Based on this information, the nurse assesses the woman for what condition?
Long, difficult labor
Prolonged pregnancy
Longer than 42 weeks gestation (miscalculated EDD/late prenatal care) Risk to fetus : Insufficient placental function Late decelerations/decreased variability Oligohydramnios (accompanies placental insufficiency/cord compression) Meconium aspiration IUGR Maternal risk: Dysfunctional labor Traumatic birth Hemorrhage Psychologic : fear of induction/possible C-section/newborn problems Fatigue Therapeutic management : Determine accurate, EDD Assess fetal condition BPP Consider induction if cervix favourable Nursing consideration Educate about procedures Provide support
Cesarean birth, fetal risks
Lung immaturity is the greatest risk if the fetus is delivered preterm Inadvertent, preterm birth Transient tachypnea Persistent, pulmonary HTN of the newborn Traumatic injury
Mild preeclampsia
May not have knowledge of mild preeclampsia until BP is assessed BP >140/>90 (either number) Proteinuria <1 in 24 hours +2 protein dipstick Generalized edema may be present -the Morphle were there is the more the VP will go up in the more pain they will be in Identify and assess edema -look at the feet +1+2+3 pitting? Nonpitting? Maybe ascites
Macrosomia-fetal complications
Meconium aspiration Asphyxia Shoulder dystocia Upper brachial plexus injury Fractured clavicle Hypoglycemia Polycythemia Hyperbilirubinemia
Client with an obstetrical history of G1 P0000 received dinoprostone for cervical ripening 8 hours ago. The Bishop score at the time was 4. The Bishop score is now 10. What should the nurse do?
Monitor for onset of labor
Strongest predictors of PTL
Multiple gestation Bleeding during pregnancy Cervical vaginal fibronectin Abnormal cervical length on ultrasound History of previous preterm birth Abnormal vaginal flora Infection Possible link with paternal smoking
Treatment plan for ROM
Near term Favorable cervix without spontaneous labor -Consider induction Unfavorable cervix -Delayed induction 24 or more hours to allow cervix softening an initiation of antibiotics Preterm < 34 weeks (physician weighs risks of infection against risks of prematurity) -Consider gestational age -Amount of remaining amniotic fluid -Fetal lung maturity Maternal antibiotics (48 hours, IV followed by 5days oral) -Inhibit infection causing ROM or development of infection -Delays onset of labor -Commonly used drugs: Ampicillin Erythromycin Amoxicillin Azithromycin
High risk factors for GDM
Nonwhite Prior history of GDM Prior birth of LGA infant Marked obesity Diagnosis of PCOS HTN Glycosuria Strong family history of type 2 DM
Nursing considerations for induction and augmentation of labor
Observe Fetal response -Hypertonic contractions reduce uteroplacental blood flow -Assess FHR pattern -Reducer stop in fusion for non-reassuring FHR -Side lying position -Oxygen by facemask Observe maternal response -Assess uterine activity -Assess BP and pulse -Be aware of pain management techniques -Record I&O -Observer for signs of water intoxication -Assess for uterine Atony in postpartum.
complications associated with preterm labor
Obstetric: Shortened cervical length <25mm Previous preterm birth PROM Preeclampsia or bleeding disorders Fetal: IUGR Oligohydramnios Chromosome or birth defects Social or environmental factors: Inadequate prenatal care Domestic violence Maternal smoking Homelessness
Nursing considerations for induction of labor
Obtain informed consent Careful monitoring of labor Oxytocin protocols Discuss pain relief measures Effective use of relaxation and breathing techniques Keep woman and support person informed of progress
Passage problems
Occur with variation of bony pelvis or soft tissues -Pelvis Small or abnormal shape Slow labor, obstruct descent Poor contraction, slow dilation -Soft tissue Bladder distention Encourage voiding every 1-2hours Place Foley catheter after epidural or if unable to void -fetal anomalies hydrocephalus or large fetal tumor prevents dissent -CPD: fetus is larger than passageway Causes of passageway contractures: narrowed pelvis or soft tissue dystocia (fibroids, bandl ring, stool, full bladder) Reproductive tract anomalies can also impact birthing ability Maternal implications : prolonged labor, rupture of membranes, increased risk of uterine rupture, maternal soft tissue necrosis, difficult-forceps assisted birth Fetal implications: danger of cord prolapse, excessive cranial molding, damage to fetal skull, damage to CNS
Prolapsed umbilical cord
Occurs after ROM Compressed between fetus and pelvis Interruption blood flow through court interferes with fetal oxygenation Potentially fatal Complete : visible or palpable Occult: presents along with shoulder or head -Can't be seen or palpated but suspected -Change in FHR (bradycardia or variables) Risks : Fetal high station Very small fetus Breech presentation (footling) Transverse lie Hydramnios
PPROM
Occurs before the 37th completed week of gestation Absence of labor Most common cause is infection or bacteria in the genital tract Patient reports a gush or leakage of fluid from the vagina Any increased vaginal discharge should be evaluated Complications : Increased risk for infection Chorioamnionitis can be both a cause and a result of PROM -Characterized by maternal fever and uterine tenderness Risk of RDS Fetal sepsis Malpresentation Umbilical cord prolapse or compression Non-reassuring FHR tracings Premature birth Increased, perinatal morbidity and mortality
Intrauterine infection
Occurs in normal or prolonged labor S/s -FHR-persistent tachycardia (>160) for 10 minutes or longer -Maternal fever Assess temp q 2-4hrs normal labor Assess temp q 2hrs after ROM Assess temp q 1hr if elevated -Maternal tachycardia or tachypnea Assess pulse , RR, & BP hourly -Amniotic fluid Note color, odor Nursing diagnosis : risk for infection Interventions to ⬇️ risk for infection Hand washing PPE Limit vaginal exams (maintain aseptic technique) Keep peripads clean and dry Perineal care
macrosomia
Often the result of imbalance between glucose and insulin in those with diabetes -Glucose absorbed from the mother -Fetus produces pancreatic insulin -Increases fat deposits Maternal obesity contributes to a larger fetus
Amniotic fluid complications
Oligohydramnios -Less than 300 mL of amniotic fluid Hydramnios -Greater than 2 L of amniotic fluid Meconium -First stool of the infant -Meconium staining Chorioamnionitis Fetal risks: Fetal skin and skeletal abnormalities Pulmonary hypoplasia Cord compression Fetal head compression
Factors associated with hypotonic labor pattern
Overstretched uterus(twin gestation) Large fetus Hydramnios Grand multiparity Bladder or bowel distention Cephalopelvic disproportion CPD
GDM risk factors
Overweight Older than 25 Previous birth outcome often associated with GDM GDM in previous pregnancy History of abnormal glucose tolerance Family history of diabetes Member of a high risk ethnic group
Treatment if tachysystolic pattern continues and prolonged latent phase develops
Oxytocin infusion or amniotomy may be considered Maternal repositioning Oxytocin may be decreased or stopped
Intrapartum emergencies: placental abnormalities
Placenta accreta: abnormally, adherent, placenta -Immediate or delayed hemorrhage Placenta increta : placenta, penetrates, uterine muscle Placenta percreta : placenta penetrates all the way through uterus -Hysterectomy necessary if large portion of the uterus involved Methotrexate maybe used to speed degeneration of remaining placental tissue
Contraindications for induction and augmentation of labor
Placenta previa (if they dilate they'll bleed) Vasa previa Umbilical cord prolapse Abnormal Fetal presentation Fetal presenting part above the pelvic inlet Previous surgery in the upper uterus
Pathophysiology of preeclampsia
Poorly understood A disease of the placenta Arterial transformation in the placenta is incomplete -Vasospasms due to gradual loss of resistance to angiotensin 2 -Endothelial cell damage Restriction of blood flow causes endothelial cell damage and a cascade of events follows this insult -decreased perfusion to all organs, including placenta= decreased or inadequate 02 to the uterus...can cause stillbirth -prompts the utilization of platelets and fibrinogen Decreased plasma volume Activation of coagulation cascade -Increased viscosity of the blood makes it too hard for the heart to pump Alterations in glomerular endothelium HELLP syndrome
Oligohydramnios
Postmaturity Maternal hypertensive disorders with IUGR; placental insufficiency Fetal conditions- Renal malformations Clinical therapy: BPPs NSTs Serial U/Ss Induction of labor when fetus at term Continuous EFM to detect cord compression Possible amnioinfusion after membrane rupture to decrease variable decelerations in FHR Labor care : Monitor for non-reassuring FHR Maternal repositioning Assess newborn for congenital anomalies
Maternal exhaustion
Pregnancy = sleep deficit -Fetal movement, frequent, urination, shortness of breath Labor progresses= reserves depleted -Verbal expression of tiredness, fatigue, exhaustion, or frustration -Ineffective coping techniques -Change in pulse, respirations and BP Interventions= target, conserving, maternal energy -Control environment(dim lights,⬇️ noise, comfortable temperature of room) -Position to comfort(change every 30 minutes) -Shoulder and back rub -Sacral pressure -Birthing ball -Encourage rest(especially after epidural is in place) Coping skills -Explain purpose and benefit of medication therapy and position change -Encourage visualization -Encourage and praise efforts -Keep informed of progress
Techniques for operative, vaginal birth
Preparation -Empty bladder -Cervix completely dilated and membranes ruptured -adequate anesthesia (if no epidural, pudendal block) Classification of techniques for operative, vaginal birth -Outlet: fetal head on perineum -low: leading edge of fetal skull at station +2 -Mid: leading edge of fetal score between 0 and +2 Forceps: locking blades apply to fetal head Vacuum extraction: cup attached to fetal head and traction applied r/o cephalohematoma= Watch for hyperbilirubinemia Nursing considerations: -Observe mother for trauma after birth (bright, red bleeding with firm fundus) -Observe neonate for trauma after birth Facial asymmetry {forceps}, cephalohematoma {Vacuum extraction}
Risk factors for Preeclampsia
Primigravida Age extremes Pre-gestational diabetes Pre-existing HTN Pre-existing renal disease Pre-existing collagen disease Multiple gestation Hydatidiform mole Previous Preeclampsia Family history Obesity Periodontal disease Antiphospholipid antibody syndrome (autoimmune) Rh incompatibility African-American ethnicity Pregnancies that result from donor insemination, oocyte donation, or embryo donation
Nursing care for precipitate birth
Promote Fetal oxygenation and maternal comfort -Sidelying position to slow descent, minimize perennial tears, and promote maternal oxygenation -Maintain adequate blood volume(⬆️IV fluid) -Stop oxytocin -Promoting comfort will be difficult because there is a little time for preparation or use of coping skills -Pharmacologic measures may not be effective(newborn respiratory distress with opiate use) Nurse MUST remain with patient (support and assist with emergency birth) -Don gloves -Support head as emerges -Do not hold legs closed or hold head in
Cesarean birth, nursing considerations
Provide emotional support Teach Promote safety Provide postoperative care
A client diagnosed with preeclampsia WITHOUT severe features has been advised to stop working and be on light activities and bedrest at home. She asks why this is necessary. What is a good response for the nurse to give the client?
Reclining will increase the amount of oxygen that your baby gets
Management of uterine rupture
Recognize s/s -Interior of uterus may be seen through cervix or protruding into the vagina -Severe pelvic pain -Massive hemorrhage, shock and pain quickly evident Physician will attempt to replace uterus to normal position -Laparotomy or hysterectomy may be required Rapid fluid and blood replacement Tocolytic Drug -relax uterus for replacement Postpartum -Assess find us for firmness, height, position -Observe for tachycardia, falling BP or urinary output associated with hypovolemic shock -Observe for cardiac dysrhythmias
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which complication.?
Reduced fetal oxygen supply
PROM
Rupture of amniotic sac prior to start of labor, regardless of length of gestation PPROM is prior to 37 weeks Possible causes: Infection Weakened amniotic sac (amniocentesis) UTI Chorioamnionitis Previous preterm birth Fetal abnormalities or malpresentation Uterine overdistention (multiple gestation) Placenta previa /abruptio Placentae Cervical insufficiency History of laser conization or loop electrosurgical excision procedure (LEEP)
SPASMS
Significant blood pressure changes may occur without warning Proteinuria is a serious sign of Renal involvement Arterioles are affected by vasospasms that result in endothelial damage and leakage of intravascular fluid into the interstitial spaces. Edema results. Significant laboratory changes, (most notably, liver function tests and the platelet count) signal worsening of the disease Multiple organ systems can be involved: cardiovascular, hematological, hepatic, Renal, & CNS Symptoms appear after 20 weeks of gestation
Rheumatic heart disease
Sometimes follows strep pharyngitis May cause scarring of the heart valves -The mitral valve is the most common site of stenosis May lead to pulmonary HTN, PE, or CHF
A woman has a history of bilobed placenta, each with his own circulation. What condition does this describe?
Succenturiate placenta
Nursing care of the woman with suspected CPD
Support couple in coping: keep them informed Nursing actions during TOL -Similar to any labor, but dilation in fetal descent assessed more frequently Continuous monitoring of contractions and fetus Report signs of non-reassuring fetal status Assist mother with positioning to increase pelvis diameters -Sitting or squatting -Changing from one side to another or hands and knees position may help move fetus to OA position
Maternal risks of operative vaginal birth
Vaginal or perineal lacerations Infection secondary to lacerations Increase bleeding Bruising Perineal edema (ice packs for 24 hours)
Signs of non-reassuring fetal status
Variation from normal heart rate Decreased fetal movement Meconium stained amniotic fluid Ominous FHR patterns -Persistent late decelerations -Persistent severe variable decelerations -Prolonged decelerations -Loss of variability Tachycardia and bradycardia
Variations related to umbilical cord insertion and the placenta
Velamentous cord insertion -Fetal vessels separate at distal end and insert into placenta away from the margin -Vessels are not protected by Wharton's jelly -May be able to feel pulsations of the umbilical cord -Lacerations of the vessels may occur
