CH 22: Complications Occurring During Labor and Delivery

hypertonic contractions

Uterine contractions that are too long or too frequent, have too short a resting interval, or have an inadequate relaxation period to allow optimal uteroplacental exchange. Marked by an increase in resting tone to more than 15 mm Hg. Most commonly seen in the latent phase of labor.

Hyptonic uterine dysfunction

A condition in which the uterine contractions are too uncoordinated or not strong enough to dilate the cervix. Occurs in the first stage of labor.

A mother in the active phase of labor has been contracting for 4 hours. The contractions are occurring infrequently and not lasting very long. When the nurse palpates the uterus during a contraction it feels soft. The nurse should anticipate receiving which prescription from the obstetric provider? A) Administer oxytocin B) Place in side-lying position C) Prepare for epidural anesthesia D) Obtain internal monitoring

A) Administer oxytocin The mother is experiencing hypotonic contractions. Oxytocin is started to augment labor and make the contractions more efficient. External monitoring is used unless there is rupture of membranes; if this occurs, internal monitoring can be used to evaluate the effectiveness of the contractions. Positioning and anesthesia will not affect the tone of the uterus.

In terms of planning care, why is the development of a pathologic retraction ring important? A) It precedes uterine rupture. B) It suggests cesarean birth is no longer possible. C) It denotes a multiple pregnancy is present. D) It identifies that the pelvic division of labor is beginning.

A) It precedes uterine rupture. A pathologic retraction ring implies the uterus is stressed to its maximum; uterine rupture may follow.

The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true? A) Late decelerations B) Early decelerations C) Variable decelerations D) Mild decelerations

A) Late decelerations When the fetus is being deprived of oxygen the fetus will demonstrate late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.

The mother comes to her prenatal appointment. She tells the nurse that it feels like the baby is kicking on her bladder and it is harder to breathe. The nurse suspects the fetus is in breech position. Which procedure would the nurse implement to determine the position of the baby? A) Leopold maneuvers B) McRoberts maneuver C) Rubin maneuver D) Gaskin maneuver

A) Leopold maneuvers Diagnosis of breech presentation is usually by Leopold maneuvers. These maneuvers are done by palpating the maternal abdomen to feel the location of the fetal parts (head, back, buttocks, etc.). A sign of breech presentation is the mother's report of pressure from the fetal head against the fundus and kicking in the lower abdomen. McRoberts, Rubin, and Gaskin maneuvers are all procedures used in the delivery room when shoulder dystocia is present.

The nurse is caring for a laboring mother. The mother continues to complain of back pain. The nurse instructs the mother the pain is occurring because the fetus is in which position? A) Occiput posterior B) Occiput transverse C) Left occiput anterior D) Right occiput anterior

A) Occiput posterior The fetal position is the position of the presenting part in relation to the maternal pelvis. The most common fetal positions are left occiput anterior and right occiput anterior. The most common fetal malposition is occiput posterior (OP). OP position causes severe maternal backache. There is no fetal position of occiput transverse.

The nurse is caring for a laboring mother who is experiencing a protracted active phase of labor. The nurse prepares for which two interventions to assist the mother through this phase of labor? A) Oxytocin and amniotomy B) Amniotomy and epidural anesthesia C) Oxytocin and epidural anesthesia D) Amniotomy and internal monitoring

A) Oxytocin and amniotomy A protracted active phase is often treated with oxytocin and amniotomy. There are much better outcomes when both interventions are utilized together. Amniotomy without the use of oxytocin does not appear to improve outcomes. Internal monitoring will have no effect on contractions. An epidural provides pain relief and does not affect the quality of contractions.

Which nursing interventions during labor help the nurse identify a breech presentation in the fetus? Select all that apply. A) Palpating the fetal head in the fundus during Leopold maneuvers B) Locating fetal heart tones slightly above the umbilicus C) Noting the passage of meconium after the rupture of membranes D) Checking for Bandl's ring formation after rupture of membranes E) Assessing for a fetal body depression such as the neck or abdomen

A) Palpating the fetal head in the fundus during Leopold maneuvers B) Locating fetal heart tones slightly above the umbilicus C) Noting the passage of meconium after the rupture of membranes

A mother who had a cesarean delivery with her second child wishes to deliver her third baby vaginally. The nurse prepares the mother for an induction of labor. Because of the previous cesarean birth the nurse knows which classification of drugs will not be used in the induction process? A) Prostaglandins B) Oxytocin C) Ergot alkaloids D) Laminaria

A) Prostaglandins Any labor induction contributes to the risk of uterine rupture in women with a history of cesarean section. Because of the increased risk of rupture with prostaglandins their use is contraindicated in women with previous cesarean birth. There is also risk with oxytocin but it is not contraindicated. Ergot alkaloids (methergine) are more useful postpartum to keep the uterus contracted to prevent bleeding. Laminaria (seaweed) is useful to help soften the cervix prior to induction but does not stimulate contractions.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia? A) diabetes B) preterm birth C) nullipara D) pendulous abdomen

A) diabetes Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client? A) hypotonic contractions B) hypertonic contractions C) uncoordinated contractions D) Braxton Hicks contractions

A) hypotonic contractions With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.

A laboring mother continues to attempt to push. The nurse instructs the mother in breathing techniques to help this urge, teaching the mother that she should not push until the cervix is completely dilated because: A) pushing will cause the cervix to swell. B) pushing will cause a laceration to the undilated cervix. C) prolonged pushing will cause fetal distress. D) prolonged pushing will cause vaginal bleeding.

A) pushing will cause the cervix to swell

The diabetic mother has been in active labor for 9 hours and has only reached 3 cm dilation. It has been determined by ultrasound the fetus is very large. The decision has been made to deliver the fetus via cesarean. How much time does the nurse have to prepare the client before the surgery begins? A) 15 minutes B) 30 minutes C) 45 minutes D) 60 minutes

B) 30 min A cesarean section that occurs after the onset of labor is referred to as an emergency cesarean and, as dictated by national standards, must begin within 30 minutes of the decision to operate. The nurse would need to prepare the mother for surgery within this time frame.

A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds which can prolong labor. Which compounds is the nurse referring to in the explanation? A) prostaglandins B) catecholamines C) oxytocin D) relaxin

B) catecholamines Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.

The nursing student demonstrates an understanding of dystocia with which statement? A) "Dystocia is diagnosed at the start of labor." B) "Dystocia is not diagnosed until after the birth." C) "Dystocia is diagnosed after labor has progressed for a time." D) "Dystocia cannot be diagnosed until just before birth."

C) "Dystocia is diagnosed after labor has progressed for a time." Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the client and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule? A) 2 cm/hour for cervical dilation B) 1/2 cm/hour for cervical dilation C) 1 cm/hour for cervical dilation D) 1/4 cm/hour for cervical dilation

C) 1 cm/hour for cervical dilation In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

The nurse instructs the pregnant mother that it will necessary to collect swabs for group B streptococcus at which prenatal visit? A) 32 weeks' gestation B) 34 weeks' gestation C) 36 weeks' gestation D) 38 weeks' gestation

C) 36 weeks' gestation In the pregnant woman GBS is usually asymptomatic. Women are usually checked for GBS colonization of the urogenital tract in the 36th week of pregnancy. The CDC recommends women be checked somewhere between 35 and 37 weeks.

Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur? A) Fourth stage of labor B) Third stage of labor C) Second stage of labor D) First stage of labor

C) Second stage of labor Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: A) longer lengths of labor. B) increased number of overall pregnancies. C) increasing birth weight. D) poor quality of prenatal care.

C) increasing birth weight. Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in up to 2% of vaginal births.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type? A) first-degree laceration B) second-degree laceration C) third-degree laceration D) fourth-degree laceration

C) third-degree laceration

Hypertonic uterine dysfunction

Contractions are frequent, have irregular tone, and do not contribute to cervical effacement or dilation or fetal descent. Often, the uterus does not relax completely between contractions. Occur in the midsection of the uterus.

Occult cord prolapse

Cord becomes trapped between fetus and maternal parts.

Overt cord prolapse

Cord slips out of vagina.

The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? A) Genetic abnormality B) Premature rupture of membranes C) Preeclampsia D) Placental abruption

D) Placental abruption The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. Trauma does not cause preeclampsia (which is related to various issues in the mother) nor does trauma usually cause PROM.

A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem? A) The fetus is macrosomic. B) mother is fighting the contractions. C) The mother has a small pelvic opening. D) Uterine contractions are weak and ineffective.

D) Uterine contractions are weak and ineffective.

A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem? A) The fetus is macrosomic. B) The mother is fighting the contractions. C) The mother has a small pelvic opening. D) Uterine contractions are weak and ineffective.

D) Uterine contractions are weak and ineffective. Labor dystocia indicates that the labor is progressing too slowly. Reasons for this are described as due to the "four P's", which are passageway, passenger, power and psyche. A power problem involves either ineffective contractions in either quality or quantity or the mother is too tired to push when needed.

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth? A) extensive lacerations B) monitor for a cardiac anomaly C) assess for cleft palate D) brachial plexus assessment

D) brachial plexus assessment The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding? A) well coordinated. B) poor in quality. C) brief. D) erratic.

D) erratic. Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix.

Third degree perineal laceration

Involves the skin of the fourchette, the perineum, the perineal body and the anal sphincter

precipitous labor

Labor that lasts 3 hours or less from onset of contractions to time of delivery

McRoberts maneuver

McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

Bandl's ring

an abnormal retraction ring that occurs in obstructed labor. It is a sign of impending rupture of the lower segment of the uterus, which becomes progressively thinner as Bandl's ring rises upwards. Immediate action to relieve the obstruction is then necessary, usually in the form of Caesarean section

hypotonic contractions

weak, inefficient, or completely absent. Unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg.

cephalopelvic disproportion

when the fetal head is larger than the maternal pelvic opening