Childbirth at Risk and Birth-Related Procedures

uterine rupture s/s of hemorrhage

- FHR impact may be noted first - if complete, pain sharp and ctx cease (fetal mortality high)

chorioamnionitis tx

- IVF - antibiotics - facilitate delivery - Followup diagnosis/treatment

indications labor induction/augmentation

- post dates - maternal hypertension disorder/diabetes - IUGR - older maternal age

placenta previa risk factors

- previous placenta previa - previous c/s - induced abortion - women over age 35 other - multiple gestation - close-spacing - smoking - cocaine

nursing interventions abruptio placenta

- promote fetal oxygenation - emotional support - IV access, fluid replacement, type/cross blood, - urinary cath - surgical prep for C/S

if non-reassuring fetal patterns on oxytocin

- reduce/stop oxytocin and increase IVF - left lateral - O2 8-10 L/min - notify provider - administer terbutaline or mag sulfate

transverse incision

- slower - less visualization - not easily extended - less chance of hernia/dehiscence - less blood loss - VBAC possible - less of a visible scar when healed

signs of possible shoulder dystocia

- slowing of progress of labor - caput succedaneum that increases in size - cardinal sign: turtle sign, no external rotation

prolapsed cord risk factors

- small fetus - high station - breech position - transverse lie - hydramnios/polyhydramios (extra fluid)

chemical induction: prostaglandins

- sometimes also effective in inducing labor w/o use of oxytocin - require maternal assessment and FHR and uterine monitoring before, during, after - major adverse reaction hyper-stimulation of uterine ctx

INTRAPARTUM EMERGENCY: Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism)

- through tear in amnion, chorion, amniotic fluid enters the maternal circulation, obstructs maternal pulmonary vessels - ACUTE maternal respiratory distress and circulatory failure - DIC occurs simultaneously

primary concerns with fetal version

- umbilical cord compression - disruption of placental site and subsequent abruption - mixing of maternal and fetal blood

abnormal labor pattern... increases risk of maternal and fetal complications

- uterine rupture - lacerations of birth canal/perineal trauma - amniotic fluid embolism - pp hemorrhage - fetal hypoxia - fetal intracranial hemorrhage

placenta previa management

- vaginal rest/bedrest with BR privilages - maternal assessment of bleeding (report increase) - daily "fetal kick counts", uterine/fetal monitoring - serial lab values (H/H) and hep lock - ultrasounds q 2-3 weeks - fetal surveillance (NST/biophysical profile_

placenta previa screening

***SCREEN ALL women c/o vaginal bleeding after 24 weeks! (sometimes mistaken for heavy bloody show)

nursing role anaphylactoid syndrome of pregnancy

- CPR/O2, mechanical ventilation - continous fetal and maternal assessment - replacing volume with fluid, blood products - correction of coagulation disorder - emergency c/s delivery once stablaized

priority nursing assessments abruptio placenta

- amount/nature of bleeding - pain - maternal vital signs - fetal well-being - uterine ctx - length of gestation - laboratory data - s/s concealed hemorrhage OR shock

fetal risks for shoulder dystocia

- asphyxia (CNS injury) - brachial plexus damage - fracture of humerus or clavicle

Post-amniotomy Care

- assess FHR for non-reassuring patterns - assess fluid characteristics/time - temp q 2 hr

oxytocin nursing considerations

- assessment of mother/infant for complications AND take immediate corrective action as needed

uterine rupture prevention

- avoid VBAC after classical C/S - monitor medically augmented labor (discontinue PRN) - fluid/blood replaced and birth precipitated - laparoscopic repair if partial - hysterectomy if complete

vertical (classic) incision

- better visualization - may be necessary with placenta previa - may be better for obese women - greater chance of hernia/dehiscence - no subsequent vag births possible - more blood loss

risk factors for dystocia

- body build (30 lbs or more overweight, short stature) - uterine abnormalities - fetal malpresentation and or position - cephalopelvic disproportion - overstimulation with oxytocin - fatigue, dehydration, electrolyte imbalance

nursing management of shoulder dystocia

- call for help - prepare for resuscitation - assist with management interventions

pre-conditions for amniotomy

- cephalic presentation - presenting part engaged, up against cervix - 2cm dilation

mechanical induction: Cook's catheter

- cervical ripening balloon with stylet - inserted prior to induction when cervix is unfavorable - creates steady pressure on internal and external os through the dilation process ALSO: stripping membranes

s/s of infection amniotomy

- chill - uterine tenderness - foul-smelling drainage - tachycardia

oxytocin

- common induction/augmentation - frequently follows cervical ripening - requires concurrent continuous uterine and FHR monitoring - piggy-backed into main line - Start slowly and increase gradually (on pump) Protocols regulate

non-invasive interventions to augment labor

- emptying bladder - ambulation - position changes - amniotomy - relaxation measures - hydrotherapy - nourishment/hydration

factors that increase shoulder dystocia

- fetus > 4000 g - previous dystocia

amnioinfusion

- for oligohydramnios - Increases volume of fluid when oligohydramnios causing cord compression (variable decels) - Relieves pressure on cord - Bedrest, FHR monitoring, frequent changing of underpads from constant leaking

forceps or vacuum-assisted births necessary conditions

- fully dilated cervix - membranes ruptured - presenting part engaged - absense of CPD

placenta previa risks

- hemorrhage - shock - emergency C/s - preterm birth - hemorrhage postpartum

maternal risks for shoulder dystocia

- hemorrhage rt/ uterine atony or rupture - trauma to perineum - bladder, liver injury - endometritis

risks labor induction/augmentation

- hypertonic uterine activity - C/S birth - uterine rupture

oxytocin indications

- inductions/augmentation of labor at or near term - control of postpartum bleeding

prolapsed cord interventions

- knee-chest position - reclining on left side hips higher than shoulders OR gloved/gel fingers can be inserted into vagina to push fetal head off of cord

background risk factors for uterine rupture

- labor stimulation (oxytocin, prostaglandin) - over-distended uterus - malpresentation - difficult forceps- assisted birth

interventions to induce labor

- laxative use - nipple stimulation - acupuncture

general disadvantages of c/s

- longer physical recovery time - delayed breastfeeding - greater financial expenditure - potential for anger, low self-esteem, body image

external version

- manipulation of fetal presentation from the outside uterus - usually, attempt to turn a fetus from breech or shoulder to vertex presentation

abruptio placenta risk factors

- maternal HT - cocaine - abdominal trauma - twins - prior abruption - smoking - older age

chorioaminotitis s/s

- maternal fever - fetal tachy - sore uterus - foul smelling or cloudy amniotic fluid

abruptio placentae sx

- may be silent - dark red bleeding - uterine tenderness - uterine tetany (ctx) - abdominal pain - FHR not reassuring - suspect with sudden onset of intense, localized uterine pain with or w/o uterine bleeding

chemical : prostaglandins example

- misopristol - dinoprostone cervidil

oxytocin adverse reactions

- nausea - vomiting - headache - maternal hypotension - uterine hyper-stimulatuion - fetal distress

indications for forceps or vacuum-assisted births

- need to shorten 2nd stage of labor - dystocia - deficient maternal expulsion efforts - reversal of dangerous maternal condition - birth of fetus in distress/abnormal presentations

best candidates for TOLAC

- only one previous C/S with a low transverse uterine incision (esp if not related to dystocia) - risk of complications and lack of success with each previous C/S

placenta previa s/s

- painless vaginal bleeding - bleeding BRIGHT RED - uterus non-tender, relaxed - FHR typically remains reassuring, unless major detathcment - fundal height may be high r/t placenta impendign descent

retained placenta

retention beyond 30 minutes

A nurse is preparing a prenatal client with a breech presentation for an external cephalic version (ECV). What condition must be met prior to this procedure? A. 34 weeks gestational age B. Fetal breech must be engaged in the pelvis C. Reactive nonstress test D. Mild labor contractions

C. Reactive nonstress test The fetus must be more than 36 weeks' gestation, with a reactive nonstress test, and not engaged in the pelvis.

INTRAPARTUM EMERGENCY: Shoulder Dystocia

Head born, anterior shoulder cannot pass under pubic arch - often unexpected- high potential for litigation

hypotonic uterine contractions

Fewer than 2 - 3 ctx. in a 10 minute period

tachysystole contractions

>90 sec, <2 min apart

The nurse is caring for a laboring client with a known history of cocaine abuse. What complication is most likely for this client? A. Abruptio placentae B. Placenta previa C. Polyhydraminos D. Prolapsed cord

A. Abruptio Placentae Abruptio placentae is the most likely complication for a client with a known history of cocaine abuse. This is because cocaine causes severe uteroplacental vasoconstriction and regional hypertension, which causes the placenta to separate from the uterine wall. Placenta previa may be a complication for women with multiple prior cesarean births. Prolapsed cord may be a complication with hydramnios, a small fetus, and a breech presentation. Polyhydramnios may be a complication of women with diabetes.

The nurse is caring for a client who is not in labor but has been diagnosed with ruptured membranes at 30 weeks' gestation. For what intervention should the nurse prepare? A. Digital vaginal administration B. Administration of magnesium sulfate C. Induction of labor D. Amniofusion

B. Administration of Mag Sulfate Magnesium sulfate is indicated for the prevention of infant neurological impairment anytime preterm delivery is expected. Induction of labor will only be done if the risks of complications such as infection outweigh the benefits of continuing the pregnancy. Digital vaginal examination increases the risk of infection in cases of prolonged rupture of membranes. Amnioinfusion is only indicated when there is evidence of cord compression.

A neonate whose mother declined prenatal ultrasounds is admitted to the special care nursery. His estimated gestational age by LMP was 42 weeks and 2 days. His 5-minute Apgar score was 6 and the nurse notes his skin is loose and peeling. This infant is likely to be affected by: A. Brachial plexus palsy B. Dymaturity syndrome C. Hypoxia D. Sepsis

B. Dymaturity syndrome Dysmaturity syndrome occurs in postterm infants who lost weight at the end of the pregnancy due to placental insufficiency. Brachial plexus palsy is a complication of shoulder dystocia. Hypoxia and sepsis are evidenced by abnormal respirations, color, and heart rate.

The nurse is preparing to assist with administration of amnioinfusion (AI). Which of the following nursing interventions is most appropriate? A. Monitor the fetal heart rate through intermittent electronic fetal monitoring (EFM) B. Obtain a solution of warmed, sterile normal saline C. Ensure that fluids infused into the uterus are not expelled D. Increase the rate of oxytocin infusion

B. Obtain a solution of warmed, sterile normal saline

The nurse educator is creating an in-service for student nurses who are completing their mother-baby clinical rotation. When discussing misoprostol (Cytotec), which of the following components is incorrect and should be omitted from the educational content? A. Misoprostol should only be administered where uterine activity can be monitored continuously if needed. B. The safe dosing interval is 3-6 hours. C. The initial dosage of misoprostol for induction is 50 mcg. D. Pitocin should not be administered less than 4 hours after the last misoprostol dose.

B. The safe dosing interval is 3-6 hours. he initial dosage of misoprostol for induction is 25 mcg. Recurrent administration of misoprostol should be at intervals of 3-6 hours. Pitocin should not be administered less than 4 hours after the last misoprostol dose. Misoprostol should only be administered where uterine activity and fetal well-being can be monitored continuously if needed

A nurse is assisting the primary healthcare provider with a forceps-assisted birth. What information from the nurse allows the primary healthcare provider to determine the appropriate time to apply traction? A, the current dose of oxytocin B. When a contraction begins C. the estimated midpoint between contractions D. When a contraction ends

B. When a contraction begins The nurse advises the primary healthcare provider when a contraction is present because traction is applied only with a contraction, not prior to or following a contraction. The current dose of oxytocin does not influence the timing of traction.

chorioamnionitis

Bacterial Infection (E coli, Strep) of chorion, amnion and amniotic fluid

A nurse is caring for a client during an amnioinfusion. Which fetal heart rate (FHR) pattern would be an expected outcome of a successful amnioinfusion? A. An increase in variable decelerations B. FHR rate of 160-180 BPM C. A decrease in variable decelerations D. FHR rate of 100-110 BPM

C. A decrease in variable decelerations Variable decelerations should decrease, not increase, following an amnioinfusion, because the fluid buffers the cord from being compressed. There should be no bradycardia or tachycardia.

A nurse is admitting a laboring client with a breech presentation. Which complication occurs more frequently in the setting of breech presentation? A. Respiratroy distress B. Retained Placenta C. Cord prolapse D. Neonatal hypoglycemia

C. Cord Prolapse Cord prolapse occurs more readily in breech presentations because the breech does not fill the pelvic inlet or become as well applied to the cervix as the head. Neonatal hypoglycemia occurs more frequently in the setting of maternal diabetes. Respiratory distress occurs more frequently with nonreassuring FHR tracings in labor and infection. Grand multiparity, uterine over distention, and prior uterine surgery are risk factors for retained placenta.

A nurse is planning an educational seminar on medical vs. complementary and alternative methods of cervical ripening. The nurse teaches that the medical method uses: A. Evening primrose oil B. Sexual intercorse C. Misopristol D. Blue/black cohosh herbs

C. Misopristol Misoprostol (Cytotec) is used in the medical model of care for cervical ripening, whereas blue/black cohosh herbs, primrose oil, and sexual intercourse are considered complementary and alternative methods.

Regarding vaginal birth after cesarean (VBAC), which of the following statements is true? A. Research shows no significant correlation between maternal weight and successful VBAC B. After one successful VBAC, there remains an increased risk of neonatal and maternal complications in subsequent attempts C. Misoprostol is contraindicated in women attempting a VBAC D. Healthcare costs are considerably higher for women who have a VBAC than for those who have a repeat cesarean birth

C. Misoprostol is contraindicated in women attempting a VBAC Misoprostol is contraindicated in women attempting a VBAC. After one successful VBAC, the risk of neonatal and maternal complications decreases in subsequent attempts. Research does show a significant correlation between maternal weight and successful VBAC. Healthcare costs are considerably lower for women who have a VBAC than for those who have a repeat cesarean birth.

A nurse is reviewing the charts of four clients in the birthing unit. Which client has an increased risk for an episiotomy? A. The client with gestational hypertension B. The client with a fetus in an occiput-anterior position C. The client with repetitive FHR decelerations in the second stage D. The client with abruptio placentae

C. The client with repetitive FHR decelerations in the second stage A client with repetitive FHR decelerations is at increased risk for having an episiotomy. Allowing time for the perineum to stretch may place the fetus at risk for asphyxia. A client with abruptio placentae is only at increased risk for episiotomy if it results in decelerations in the second stage. Gestational hypertension is not a risk factor in having an episiotomy.

A nurse is caring for a client with an oxytocin infusion. What is the correct nursing action prior to increasing the oxytocin rate? A. Assess cervical Dilation B. Evaluate the need for analgesia C. review the fetal monitor tracing D. Assess maternal temperature

C. review the fetal monitor tracing Assessing the fetal heart tracing is crucial for establishing fetal well-being and contraction pattern before increasing the oxytocin rate is crucial when caring for a client with an oxytocin infusion. Assessing cervical dilation and the need for analgesia should be done as clinically indicated and is unrelated to the oxytocin rate. Contractions pattern, not cervical dilation, determines the need to increase the rate. Maternal temperature is not affected by oxytocin infusion.

most common issues with passenger/passageway

CPD - macrosomia - pelvic size/shape multiple gestation malpresentation - breech - posterior - shoulder - fetal "attitude" not tucked

labor induction

Chemical and/or mechanical initiation of uterine ctx. before spontaneous onset

The nurse is assisting a mother with perineal care on the postpartum floor. The birth record indicates she had a second-degree, midline episiotomy the day before. The mother asks, "When will this stop hurting?" What is the nurse's best response? A. "The pain should be gone by tomorrow." B. "Episiotomy usually results some degree of permanent discomfort." C. "You might have an infection. It's not normal to still be experiencing pain." D. "It might be painful for several weeks."

D. "It might be painful for several weeks." The episiotomy site may be painful for several weeks. It is normal for the client to be experiencing pain the day after the procedure. This is not a sign of infection. If the repair was done by a skilled practitioner and healing proceeds normally, the client should not suffer from long-term discomfort.

The nurse is performing a pelvic exam on a laboring client and discovers a loop of cord in the vagina. What is the initial nursing action? A. Administer oxygen at 5 L per minute B. Place the client in a side-lying position C. Call the pirmary healthcare provider or nurse-midwife D. Apply upward pressure on the presenting part

D. Apply upward pressure on the presenting part The initial action is pressure to the presenting part in order to elevate it off of the cord, should the nurse discover a loop of cord in the vagina. Administering oxygen at 5 L per minute, calling the primary healthcare provider or nurse-midwife, and placing the client in a side-lying position are appropriate actions but not the initial nursing action.A nurse is preparing a prenatal client with a breech presentation for an external cephalic version (ECV). What condition must be met prior to this procedure?

The nurse is assessing a prenatal client diagnosed with possible placenta previa. What signs and symptoms should the nurse expect this client to demonstrate? A. Dark red vaginal bleeding B. absence of fetal heart sounds C. severe abdominal pain D. bright red vaginal bleeding

D. Bright red vaginal bleeding Bright red vaginal bleeding is a sign that a prenatal client has possible placenta previa. Severe abdominal pain, possible absence of fetal heart sounds, and dark red vaginal bleeding are true of abruptio placentae.

A prenatal client has been scheduled for induction of labor and tells the nurse she does not understand why her cervix needs to be softened with misoprostol. She asks, "Won't it be faster if we just start the Pitocin?" Which explanation from the nurse would be most accurate? A. Softening of the cervix does not occur in normal labor, but is required for induction. B. Misoprostol is the only effective method of cervical ripening. C. It is advisable to decline cervical ripening because it does not improve outcomes. D. Cervical ripening decreases the likelihood of failed induction.

D. Cervical ripening decreases the likelihood of failed induction. Cervical ripening decreases the duration of induction, Pitocin administration, and the incidence of failed induction. It is an evidenced-based intervention that clients should be encouraged to consider when indicated. Softening of the cervix normally occurs in late pregnancy or early labor. There are several other methods of cervical ripening, including Cervidil and intracervical balloon catheters.

A nurse in the birthing unit is caring for a client following an amniotomy. What is an appropriate nursing intervention? A. Replace expelled amniotic fluid every 1-2 hours B. Increase the rate of the IV maintenance fluid C. Assess cervical dilation every 2 hours D. Monitor temperature every 2 hours

D. Monitor temperature every 2 hours Due to an increased risk of infection, the nurse should monitor temperature every 2 hours following an amniotomy. Vaginal exams are kept to a minimum to decrease the chance of infection. Increasing the rate of IV fluid is not indicated. Replacing expelled amniotic fluid every 1-2 hours is unnecessary, as amniotic fluid is constantly produced.

grade 3 placenta previa

Placenta partially covers the internal cervical os.

placenta previa diagnosis

Transabdominal ultrasound

fetal version

Turning fetus from one (abnormal) presentation to another compatible with vaginal delivery

bishops score

Used to evaluate condition of cervix related to whether "inducible" (predict success) Scores given 0-3 on each: - Cervical dilation - Effacement - Station - Consistency - Position Bishop's Score 8 or higher predicts successful induction

amniotomy

artificial rupture of membranes with amniohook - to induce labor or augment labor if slow - often used in combo with oxytocin - represents a commitment to giving birth

forceps or vacuum-assisted births nursing considerations

assess/report/intervene r/t FHR patterns assess/report/intervene r/t fetal risks assess/report/intervene r/t maternal risks

Vacuum Assisted Births

attaching a vacuum cup to fetal head to assist with delivery - may be continuous or intermittent - preferable to forceps

cesarean section birth indications

benefits to fetus r/t - CPD - malpresentation - placental abnormalities (previa or abruptio) - dysfunctional labor pattern - fetal distress - post-dates - multiple gestaiton benefits to mom r/t - HTN disorders - active genital herpes - positive HIV status - diabetes

placenta accreta

chorionic villi attach to myometrium

INTRAPARTUM EMERGENCY: Prolapsed Cord

cord lies below fetal presenting part - Most obvious directly after rupture of membranes

complete uterine rupture

direct communication between uterine and peritoneal cavities

incomplete uterine rupture

does not extend to peritoneal cavity

forceps or vacuum-assisted births maternal/fetal risks

fetal - Ecchymosis - facial / scalp -lacerations or abrasions - facial nerve injury - Cephalahematoma - intercranial hemorrhage maternal - vaginal laceations - uterine retention - hematomas/perineal trauma

mid-forceps

fetus is engaged, but above 2+ station

low-forceps

fetus is greater than 2+ station

dystocia

long, difficult, or abnormal labor - labor dysfunction r/t the 5 Ps - primary reason for c/s - "dysfunctional labor" (most common cause)

TOLAC (trial of labor after a c/s)

major risk: uterine rupture contraindications - previous classic uterine incision (or other incision extending into fundus) - contracted pelvis - any contraindications to vaginal birth - use of oxytocin or prostaglandin gel *** use only with extreme caution in TOLAC pts***

C/S complications and risks

maternal - aspiration - Thrombophlebitis - atelectasis - hemorrhage - wound infection - bowel/bladder injury - complications of anesthesia infant - fetal injuries during surgery - potential for premature delivery if dates miscalculated - increased risk for alterations in transition

placenta increta

myometrium is invaded

placenta percreta

myometrium is penetrated

grade 4 placenta previa

placenta completely covers internal cervical os

placenta previa

placenta implanted near or over internal cervical os

grade 1 placenta previa

placenta lies in lower uterine segment but its lower edge does not cover the internal cervical os

central abruptio placentae

placenta separates centrally, blood trapped between placenta and uterine wall, concealed bleeding

abruptio placenta

premature separation all/part of placenta after 20 weeks

outlet forceps

scalp of fetus at perineum

marginal abruptio placenta

separation begins at the edge of placenta (vaginal bleeding present), external hemorrhage

labor augmentation

stimulation of stronger uterine ctx. after labor has started spontaneously (progress unsatisfactory)

Two maneuvers in "MATERNAL POSITION" to promote fetal rotation from

the lunge and hands and knees