Common Reproductive Concerns, L&D at Risk, 312 Exam 3

*Four Methods to Determine Fetal Position:*

Abdominal Inspection & Palpation Leopold's Vaginal Examination Auscultation of Fetal Heart Tones _*Ultrasound-most reliable*_

Dystocia: Dysfunctional Labor

Abnormal uterine contractions hypotonic or hypertonic Possible causes: Too much Pitocin Maternal fatigue, dehydration, fear... Analgesics/ anesthetics Uterine abnormalities Overstretched, congenital anomalies (mom)

TOCOLYTIC AGENTS:Terbutaline

Actions: relax smooth muscle (_*Uterus*__ & blood vessels) bronchodilation Side Effects Nervousness Restlessness Tremors Angina Tachycardia >110 Hyperglycemia (use cautiously with diabetic pt.) *DIABETES WILL INCREASE GLUCOSE LEVELS*

A mother expresses concern that picking up the infant whenever he cries will spoil him. What is the nurse's best response?

"Babies need comforting and cuddling; meeting these needs will not spoil him."

The membranes of a 26-year-old primigravida at 40 weeks' gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. What should the nurse do next?

Administer oxygen at 8 to 10 L by mask.

The nurse is gathering data from a female client that states she has had difficulty conceiving. Which statement made by the client would the nurse find most significant related to the difficulty getting pregnant?

"I had gonorrhea that went untreated for about 3 months."

A multigravid client in active labor at term suddenly sits up and says, "I can't breathe! My chest hurts really bad!" The client's skin begins to turn a dusky gray color. After calling for assistance, which action should the nurse take next?

Administer oxygen by face mask.

A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the nurse. After instruction about care while at home, which client statement indicates effective teaching?

"I should contact the health care provider if my temperature is 100.4°F (38°C) or higher."

Administration of Oxytocin

Administered through a secondary piggyback line Start with very small dose .5 - 2 mU/min Increase at small increments 1- 2 mU/Min every 15 to 60 minutes Increase to a maximum dose of 20 - 40 mU/min Reach a contraction pattern of: Duration of 40 - 90 seconds Frequency every 2-3 minutes

*Delivery of Placenta*

After delivery of baby, uterus begins to contract again Placenta begins to separate Bleeding begins Hematoma forms between placenta & uterine wall

Oxytocics: Uterine stimulant

Agents that stimulate uterine contractions to promote labor Induction/augmentation of labor Control of postpartum bleeding Induction of abortion Oxytocin (Pitocin)

Amniotic Fluid will continue to be produced even after ROM

Amniotic Fluid will continue to be produced even after ROM Main concerns: _*infection*__ Prolapsed Cord

Epidural Anesthesia & Analgesia

Anesthesia Loss of feeling Analgesia Pain control Anesthetic agent & an analgesic agent may be used together

A primigravida in active labor has been diagnosed with chorioamnionitis. After explaining this condition to the client, the nurse determines that the client understands the teaching when the client makes which statement?

"If left untreated, my baby might be born with an infection."

A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates that teaching about spinal anesthesia has been understood?

"The anesthetic may cause a severe headache, which is treatable."

An adolescent with pneumonia shares fears of having contracted human immunodeficiency virus (HIV). The adolescent wants to be tested but does not want parental involvement. What should the nurse say?

"The healthcare provider will run the test confidentially."

A 17-year-old high school senior calls the clinic because she thinks she might have gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most appropriate response by the nurse?

"We can see you without your parents' consent but have to report any positive results to the public health department."

Pharmacologic Treatment:Suppression of Uterine Activity

**_tocolytics* (See Pharmacotherapy Lecture for more info.) Only fairly effective at Preventing PT *birth*__ PREVENT birth for 24-48 hours to: Transfer to facility with a NICU Treat an infection/medical condition Administer corticosteroids to stimulate _*fetal lung*__ maturation _*betamethasone*_

Diameters of Fetal Skull

*Anterior Posterior Diameter* Widest diameter of the skull *Transverse Diameter* Also called Biparietal Diameter Approximately 9.25 cm across

*Fetal Presentation & Position* :attitude

*Attitude:* Describes degree of flexion fetus assumes as well as position of body parts in relation to each other *Full flexion*_ Best way for fetus to deliver Good "attitude"

Labor Assessment Acronym

*B*—Bladder (keep empty) *U*—Uterine contractions *R*—Rupture of Membranes *T*—Temperature *H*—Heart tones (fetal) *S*—Sterile vaginal exam

Signs & Symptoms of Impending Labor: bloody show

*Bloody Show* Pink tinged mucus secretion When mucus plug is expelled Occurs usually when cervix ripens & starts to dilate

Fetal Presentation & Position: complete extension

*Complete Extension* Face presentation Back is arched

First Stage of Labor:Transitional Phase

*Dilation from 8 - 10 cm* Strong & long (60 - 90 seconds) Frequency of every 2 - 3 minutes *Usually a rapid phase of labor* Full dilation & complete effacement occur Very emotional, very moody!!! May begin to feel urge to push

*Internal* Contraction Monitoring:IUPC

*IUPC: Internal Uterine Pressure Catheter* Solid or fluid filled IUPC is introduced into uterine cavity Measures changes in uterine cavity pressure Very accurate Only accurate way to determine true _*intensity*_ of ctx's Average pressure during a contraction is 50-85 mm Hg

Uterine Contractions: *intensity*

*Intensity:* Determined by IUPC or by _*palpating* When palpating fundus, "indentability" is determined Mild contractions are easily indented Strong contractions cannot be indented *external monitor cannot determine intensity. ONLY internal monitor.*

Fetal Presentation & Position: Moderate flexion

*Moderate Flexion* Military Style Chin is not flexed forward Not usually problem for delivery

*Nursing Management for Epidurals*

*Most common complication is maternal _*hypotension* IV fluids are usually administered Have patient empty her bladder prior to administration Cannot walk after administration of anesthetic agent

Landmarks of Fetal Skull

*Occiput:* Area over Occipital bone *Sinciput:* Area over Frontal bone *Mentum:* Chin

Fetal Presentation & Position: partial extension

*Partial Extension* Brow presentation Head is in partial extension

Passenger

*Passenger is _*fetus* _*head*__ is largest diameter of body Ability for fetus to pass depends on skull's structure & babies' position when it enters pelvis

Nursing Management During Labor/Delivery: ROM

*Ruptured Membranes (ROM)*: Assess for color, odor Assess FHR If questionable rupture: Nitrazine Test Tape pH 5.0 - 6.0: membranes probably intact pH 6.5 - 7.5: membranes probably ruptured Ferning Vaginal swab

Signs & Symptoms of Impending Labor: braton hicks

*braxton Hicks*__ Contractions: Have been occurring throughout pregnancy Become increasingly more uncomfortable Often confused with real labor Braxton Hicks contractions do not cause cervical changes

Signs & Symptoms of Impending Labor: lightening

*lightening*_______________ When fetus settles into pelvis 10 - 14 days prior to labor for Nulliparas Unpredictable in Multiparas

Signs & Symptoms of Impending Labor:nesting

*nesting*___ Sudden Burst of Energy: Cause is unknown Often occurs 24 - 48 hours before labor starts Forewarn women to not *over-exert*

Preterm Labor & Birth

2nd leading cause of infant mortality Congenital anomalies is #1 cause of NB mortality Uterine contractions & cervical changes Between 20 weeks & <37 weeks gestation Documented cervical change, either: Effacement of 80% or more Dilation > 1 cm

Promotion of Fetal Lung Maturity

Antenatal Glucocorticoids Given to _*mom*___ -- IM injection Accelerates fetal lung maturity Can decrease intraventricular hemorrhage in preterm infants Standard of Care: Give if 24-34 weeks in preterm labor Goal: administer at least 24 hrs before delivery

amniotomy (artificial rupture of membranes)

Artificial Rupture of Membranes (AROM) Used to either augment or induce Only used to induce if cervix is ripe & *head*_ is engaged Labor usually begins within 12 hours of rupture Once AROM is performed, provider is committed to deliver

Causes of Preterm Labor & Birth

50% who give birth prematurely No identifiable risk factors _*unknown*_ cause usually May be maternal _*infection*__ May be iatrogenic (25%) Labor begins b/c of pregnancy complications Inadvertently by medical procedure Due to SROM (25%)

variability: moderate

6-25 bpm Normal- this is good!

variability: minimal

<5 bpm

Variability: Marked

>25 bpm

Due to a prolonged stage II of labor, the client is being prepared for an assisted vaginal birth. What information related to the mother and neonate's care must the nurse consider?

A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps.

After AROM

Assess color, consistency of fluid, time Assess FHT Assess for signs of infection: Temperature every 2 hours Maternal Chills Fetal tachycardia

Nursing Management During Labor/Delivery

Assess ctx's Assess Fetal Status: FHR _*110*_ to _*160*__bpm Accelerations with contractions Continue to monitor fetal status throughout labor/delivery process

Monitoring Oxytocin

Assess the following: Blood pressure, pulse, respirations every 30 - 60 minutes & every time increasing dose Contraction pattern Remember to watch for resting tone Fetal status using EFM device Concerned :TTOIV

Dystocia: Hypertonic

Assessment: - contractions/FHT - IUPC if ROM (intensity) - I & O Management: Reduce _*anxiety*_ Keep pt. informed & give clear expectations Comfort measures Analgesics for _*sedation*__-- therapeutic rest IV fluids/I&O If pattern continues &/or fetal distress 🡺 C/S

Atosiban:tocolytic

Atosiban:tocolytic Oxytocin: receptor antagonist Magnesium sulfate High dose does not prevent or delay preterm birth but does increase infant mortality Was previously used readily Low-dose magnesium sulfate may reduce the risk of cerebral palsy without increasing mortality

Vacuum-Assisted Birth

Attachment of vacuum cup to fetal head Indications & prerequisites are same as they are for forceps With exception of breech birth Suction is removed after birth of head

Second Stage of Labor: Crowning

Baby needs to change positions several times to keep it's smallest diameter of presenting part with smallest diameter of pelvis _*crowning*_: When you can start to see baby's head with pushes

Preterm Birth

Before 37 weeks' gestation Leading cause of infant morbidity and neonatal mortality United States: 12.5% of all live births Premature births account for 75% of all neonatal mortalities and 50% of congenital neurologic deficits Most common neonatal respiratory distress syndrome

Drugs for Cervical Ripening

Before drugs can safely "induce" labor, the cervix has to be ripe. During pregnancy, the cervix is elongated, rigid and constricted. When ripening takes place, the cervix shortens, softens and dilates Dinoprostone (Prepidil, Cervidil) Dinoprostone gel Dinoprostone vaginal inserts (Cervidil) Misoprostol (Cytotec) Not approved for this use

Uterine Contractions: during labor

Beginning of labor: Contractions are usually mild, last about 30 seconds & occur ~every 5 - 7 minutes As labor progresses: Contractions are moderate to strong, last about 60- 90 seconds & occur every 2 - 3 minutes *Uterine Contractions are responsible for:* *Effacement of cervix* *Dilation of cervix* *Descent of fetus*

Third Stage of Labor

Begins at time baby is born & ends with delivery of __*placenta*_ Cutting Umbilical Cord: Cord is clamped at two places & cut in between two clamps Number of vessels are counted Cord blood sample is obtained

First Stage of Labor: Latent Phase

Begins with the onset of regular contractions Mild and short contractions *Last about 30 - 45 seconds* Effacement occurs Dilation to 3-4 cm Can still walk & talk Avoid giving _*analgesia* at this time

Terbutaline

Beta 2 Adrenergic Agonist Be careful of side effects!!

Cesarean Birth

Birth of fetus through transabdominal incision of uterus May be planned or emergent May be treatment of choice If there is evidence of maternal or fetal complications

Dinoprostone & Misoprostol

Both of these agents are "prostaglandins" Both of these agents can be used for cervical ripening AND induction of labor Both of these agents are applied intravaginally

COMMAND: induction of labor

C: cooks baloon O: oxytocin M: misoprostol (cytotec) M: membrane stripping A: Arom N: nipple stimulation D: dinoprostone (cervidil)

Nifedipine (Procardia)

Calcium Channel Blocker Decreases calcium in cells Commonly used as antianginal & Antihypertensive Agent Side Effect: May cause __*hypotension*_

Nifedipine (Procardia): tocolytic

Can suppress labor for up to 48 hours Efficacy equals that of terbutaline, and safety is superior Calcium channel blocker May cause hypotension

Variable Decelerations

Cause Umbilical _*cord*_Compression More common after ROM Usually head or shoulder that compresses cord Could indicate a prolapsed cord SVE indicated to check for cord Intervention Continue monitoring (usually benign) Change maternal position Administer oxygen Administer amnioinfusion if ordered LR or NS

Late Decelerations

Cause __*uteroplacental* Insufficiency Decreased blood flow during contraction\ *This FHR pattern is concerning!!!* - need to notify HCP *Interventions:* Does not necessarily warrant immediate delivery Does warrant close observation!! TTOIV... *Turn off Pitocin* *Turn patient on her side* *Oxygen-to mom* *IV Fluids-wide open*

Early Decelerations...

Cause: _*head*_ compression Intervention: Does not require intervention Benign! May indicate Cephalo Pelvic Disproportion if they occur early in labor before engagement

Fetal Tachycardia

Causes: Early fetal hypoxia Compensation Fetal anemia Maternal dehydration Beta sympathomimetic drugs Terbutaline Intrauterine infection Maternal Hyperthyroidism

Fetal Bradycardia

Causes: Late fetal hypoxia Maternal hypothermia Maternal hypotension Prolonged umbilical cord compression Fetal arrhythmia (complete heart block)

Which information would the nurse include in a teaching plan about treatments for sexually transmitted infections?

Ceftriaxone sodium may be used to treat Neisseria gonorrhoeae infections.

Cervical Changes: Dilation

Cervix dilates to a total of _*10*cm As uterine fundus thickens, cervix thins & dilates Woman should not push & put pressure on cervix until it is completely dilated

Management of Inevitable Preterm Birth

Cervix with dilation > 4 cm is likely to deliver Transfer to High Risk Hospital is important Better outcomes!

A client with active genital herpes is admitted to the labor and birth unit. During the first stage of labor. Which type of birth should the nurse anticipate for this client?

Cesarean

Preterm Labor Management**Bed Rest*_

Commonly prescribed for Preterm Labor No evidence that this is effective There are negative effects of immobility What are they? Decreased muscle tone, weight _*loss*_, calcium loss, _*constipation*_ Isolation, _*depression*_, anxiety

A 34-year-old multigravida at 36 weeks' gestation is diagnosed with preterm labor. The client has experienced one infant death due to preterm birth at 28 weeks' gestation. On admission to the antenatal unit, the nurse determines that the fetal heart rate is 140 bpm. What should the nurse do next?

Continue monitoring the client and fetus.

A client is admitted to the labor area for induction with intravenous oxytocin because she is 42 weeks pregnant. What should the nurse include in the induction teaching plan for this client?

Continuous fetal heart rate monitoring will be implemented.

Preterm Labor Management**Hospital Admission

Contraction & EFM is _*priority*_________ SVE or Sterile Speculum Exam Cervical/ Vaginal cultures Fetal fibronectin Assessment for Amniotic Fluid leaks Maternal VS, especially temp

The primary care provider prescribes a tocolytic for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when the nurse observes which finding?

Contractions cease.

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?

Contractions will be stronger and more uncomfortable and will peak more abruptly.

A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug?

Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions.

Molding

Cranial bones overlap under pressure of contractions & passage through pelvis

Risk Factors for preterm

DEMOGRAPHIC: Nonwhite race Age Low SE status Poverty Single Substance abuse Continuous psychological stress BIOPHYSICAL: Hx PT labor/birth Infections Multifetal gestation 2nd trimester bleeding Malnourishment Diabetes Chronic hypertension Placental disorders Fetal disorders Polyhydramnios

*Fetal Presentation: denotes*

Denotes body part that will deliver first Cephalic Breech Shoulder Determined by Fetal Lie & Fetal Attitude

Cardinal Movements of Labor

Descent Flexion Internal Rotation Extension External Rotation Expulsion

First Stage of Labor:Active Phase

Dilation progresses from 4 - 8 cm _*stronger* _ & longer ctx's* lasting ~ 60 seconds Frequency of contractions is usually about every 3 - 5 minutes Painful Cannot talk through ctx's *Good time to give *analgesics*

Interventions for Mag Toxicity

Discontinue Mag Sulfate Call provider Administer *Calcium Gluconate (antidote)* Monitor maternal and fetal status Monitor Mag Sulfate labs

A 30-year-old G3, T2, P0, A0, L2 is being monitored internally. She is being induced with IV oxytocin because she is postterm. The nurse notes the pattern below. The client is wedged to her side while lying in bed and is approximately 6 cm dilated and 100% effaced. What should the nurse do first?

Discontinue the oxytocin infusion.

First Stage of Labor: (usually longest)

Divided into three phases: 1. Latent 2. Active 3. Transitional

A postmenopausal woman is worried about pain in the upper outer quadrant of her left breast. The nurse's best course of action is to:

Do a breast examination and report the results to the physician.

A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?

Document fetal well-being.

Causes of Increased Variability

Early mild hypoxia (Compensation) Fetal stimulation

Preterm Labor & Birth:Care Management

Education is Imperative! Early in pregnancy Most important factor is __*prevention*_ of preterm _*BIRTH*______ Educate: *Signs *of premature labor Early intervention is vital!

Initial Instructions for preterm birth and labor

Empty bladder Drink 2-3 glasses of fluid (more in CO) Lie down on side for 1 hr If ctx's q 10 min. or less after 1 hour - CALL Dr. When to Call Dr.: ANY vaginal _*bleeding* Leaking of _*fluid* Malodorous discharge

Other Nursing Considerations:First Stage of Labor

Encourage change of positions/ ambulation Encourage voiding Provide fluids/ ice chips Provide comfort and pain control (next slides) Support patient and coach Breathing Techniques Client teaching

An adolescent presents to a community clinic for treatment of vulvar lesions associated with type 2 herpes simplex. Which intervention is appropriate to do at this time? Select all that apply.

Escort the adolescent to a private examination room. Provide the adolescent with literature about type 2 herpes simplex.

The nurse at the gynecologic clinic is teaching the client about the results of her Papanicolaou test, which demonstrated dysplasia. Which represents the nurse's best intervention?

Explain that results show alteration in the size and shape of cells, which requires follow-up.

FHR Accelerations: Nl Fetal Response to Stress

Fetal *movement*_ During Contraction Fetal Compensation

Do not use Pitocin if...

Fetal lungs have not matured Cervix is not ripe The patient had a previous C-Section or uterine surgery The patient has active genital herpes

First Stage of Labor: Latent Phase (first labor versus multiparas)

First Labor: Latent Phase will average @ 8.6 hours Multiparas Latent Phase will average @ 5.3 hours

*Stages of Labor & Birth*

First Stage: From onset of true labor to complete dilation Second Stage: From complete cervical dilation to birth of baby Third Stage: From birth of baby to birth of placenta Fourth Stage: We will discuss during Postpartum Lecture-recovery

Forcep Delivery

Forceps should NEVER be used on a fetus that is unengaged FHR should be checked before & after forceps are applied Cord can be compressed between fetal head & forcep

Treatment of Shoulder Dystocia

Goal: Free anterior shoulder Suprapubic Pressure Maternal Position Changes Hands & knees, squatting... McRoberts Maneuver Legs are flexed apart, knees on abdomen Causes sacrum to straighten & symphysis pubis rotates

Pharmacologic Management of Pain During Labor:

Goals of Pharmacological Treatment: Relax & relieve discomfort Minimal effect on uterine contractions Minimal effect on ability to push Minimal effect on fetus

Ok to give analgesia when....

Good fetal heart pattern Contraction pattern is well established Cervix dilated: 4 - 5 in nulliparas 3-4 in multiparas Presenting part is engaged

Intermittent Fetal Heart Monitoring

Hand held doppler or fetoscope Auscultate FHR between, during & after uterine contractions Listen over fetal back for best sounds *Perform Leopolds maneuver to determine fetal positioning*

Shoulder Dystocia

Head is born, but shoulder cannot pass under pubic arch Factors: large fetus, prolonged 2nd stage, postterm pregnancy, contracted pelvic outlet

*Healthy Fetus Systemic Response to Labor*

Heart Tones (FHT): Blood Flow is decreased to fetus with every contraction Should lead to an increase in heart rate Respiratory System: Labor process aids in maturation of surfactant by alveoli Labor puts enough pressure on lungs that it clears lungs of fluid

Pain Relief Therapies During Labor

Heat & cold application Therapeutic Touch Aromatherapy Effleurage Water Showers Hypnosis

Characteristics of Transitional Phase

Hyperventilation Shaking Cramping in legs Increased sensitivity to touch Restless Apprehensive Irritable Requests for medication *Not usually a good time for analgesia* Hiccupping/ belching Nausea and/or vomiting Perspiration

Causes of Decreased Variability

Hypoxia & acidosis Drugs such as Demerol, Valium, Vistaril Depress fetal CNS Fetal sleep cycle LTV decreased Fetus of less than 32 weeks gestation

*When to medicate?-pregers*

If medications are given too early in labor, it will stop contractions/labor If medications are given too late in labor it will effect baby at delivery All systemic drugs used for pain relief during labor cross placental barrier Don't give maternal analgesia if: Preterm fetus Signs of fetal distress

Theories of Labor Onset: important facts

Important Facts: Progesterone relaxes smooth muscle Estrogen stimulates uterine muscle contractions Connective tissue loosens to allow softening, thinning & dilation of cervix

Cesarean Birth: incidence

Incidence: Cesarean Section birth rates were... 5% in 1965 20% in 1997 32.7% in 2015 31.9% in 2018 (CDC, 2020) Reasons for increase: Fetal monitoring Law suits Epidural Anesthesia Increased age with pregnancy

Tocolytics (inhibit uterine ctx's)

Indomethacin -rarely used due to fetal complications Nifedipine (Procardia) Magnesium Sulfate Terbutaline (Brethine) -Used as short term tx due to maternal complications

Labor Induction/ Augmentation

Induction: Chemical or mechanical initiation to... Contract uterus _*before*__ spontaneous onset of _*labor*_ Ripen cervix Augmentation: Chemical or mechanical _*BOOST*__labor process that has started naturally

Internal Electronic Fetal Heart Monitoring:

Internal Monitoring is only way to get a "true picture" Membranes must be ruptured, cervix dilated & head low enough to reach Can monitor fetal heart rate internally without monitoring contraction pattern internally

_*variability*

Irregular waves or fluctuations in baseline fetal heart rate Does not include accelerations or decelerations

Passageway

Is the woman's pelvis adequate for childbirth? Passage is route fetus must travel Includes: *Pelvis* *Cervix* *Vagina* *External perineum*

*Anterior Fontanel*

Junction of coronal & sagittal suture line Also called "Bregma" Diamond in shape

*Posterior Fontanel*

Junction of sagittal & lambdoidal sutures Triangular in shape

Precipitous Labor

Labor that lasts < 3 hours Pattern is > 5 contractions/10 minutes Risks: Maternal - lacerations of cervix, vagina, vulva Also, risk of PPH from exhausted muscle Fetal - hypoxia, trauma to fetal head, lack of immediate care r/t unattended birth

Care during Preterm Labor & Birth

Little or no systemic *analgesia/anesthetics* _ Left side, continuous monitoring Delay AROM until > 6 cm (Why?) Low dose pitocin, if at all Generous episiotomies or C/S delivery (????) Neonatologist/Peds present Third Stage Longer—small placenta does not readily separate

Dystocia

Long, difficult, or abnormal labor Caused by various conditions associated with 5 "Ps" Including psyche Includes clinical diagnoses: FTP Arrest of descent or dilation of cervix CPD Prolonged active phase Secondary arrest of dilation Malposition

Choice of Incision type

Low transverse uterine incision is performed in more than 90% of C Sections Preferred because it doesn't compromise upper uterine segment, less blood loss, easier to perform & repair Decrease chance of rupture with future pregnancies

Classic Incision: C-section

Made in upper body of uterus Contractile portion of uterus More blood loss Greater risk of uterine rupture with future pregnancies Allows for larger access into uterus Indicated for: Need for rapid birth Shoulder presentation Placenta previa Transverse lie Preterm breech presentation Massive hydrocephalus

A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately?

Maintain airway

Prolapsed Umbilical Cord:management

Management Relieve _*pressure*_ on cord: Position mom in knee-chest or extreme Trendelenburg position Place fingers on presenting part & push forward If cord is evident, cover with warm, wet, sterile towel (**only if not in hospital setting)

Risks of Hypotonic Dysfunction

Maternal: - Prolonged labor - Prolonged ROM (🡹 infection) - 🡹 risk of postpartum what? Hemorrhage Fetal: - 🡹 risk of infection

Footling Breech

May be single footling or double footling breech Single footling breech

Rupture of Membranes: PROM

May occur before onset of contractions Premature rupture of membranes (PROM) After PROM, 80% of women will start labor within 24 hours If labor does not start spontaneously in 12-24 hours... woman is often *induced*—if she is term

Suture Lines

Membranous space between bones Sagittal Suture Line Between parietal bones Coronal Suture Line Between frontal bone &two parietal bones Lambdoidal Suture Between parietal bones & occipital bone

Cervical Ripening Drugs

Misoprostol (Cytotec) Unlabeled use Cheap ($3.25/ 100 mcg tablet) Ripens Cervix (softens & thins) Available in tablet form Dinoprostone (Prepidil, Cervidil) Prostaglandin Agent applied to cervix Ripens Cervix (softens & thins) Available in gels or suppositories Both medications lead to: Higher success rate for oxytocin induction Need for lower doses of oxytocin Shorter induction times

Hypotonic Uterine Dysfunction

More common than hypertonic Initially makes good progress in labor Contractions then become weak & ineffective Easily dent when palpate contraction

*epidural*

Most commonly used method for pain relief 2/3 or all births in US are with epidurals Epidural Anesthesia Blocks nerve pathways Temporary loss of sensation Women are not aware of their contractions, or may feel just slight pressure Will not alter uterine contractions May effect urge to push

Dinoprostone

Most widely used for cervical ripening Shortens duration of labor, allows reduced dosage of oxytocin, decreases need for cesarean section Can also induce abortion

Post Term Pregnancy: Maternal Risks

Mostly related to birth of a large infant... Increased risk for: Dysfunctional labor Perineal lacerations Postpartum hemorrhage Postpartum infection Forceps/ vacuum extraction

Oxytocin

Natural hormone secreted by the posterior pituitary gland Pitocin is the synthetic form of Oxytocin Oxytocin targets the uterus Uterus sensitivity to oxytocin increases as the gestation increases The number of oxytocin receptors in the uterus increase as the pregnancy progresses Increases force, frequency and duration of uterine contractions. Does NOT ripen the cervix Administered IM or IV Water intoxication is a possible adverse effect if used in large doses

Nursing Interventions - PTL

Need to deal with anxiety & educate Bedrest in side-lying (lateral) position, avoid sitting Hydration Tocolytics, assess for side effects Help patient cope with enforced bedrest (exercises, back rubs, diversional activities)

Misoprostol

Not approved for cervical ripening More convenient and less expensive than dinoprostone Higher incidence of uterine tachysystole

A client plans to travel to a country where hepatitis B is common. What should the nurse advise the client about the most effective way to prevent the disease?

Observe safe sex practices.

LOA______ means:

Occiput is on maternal left side, pointing anterior Fastest deliveries are ROA or LOA *Posterior Deliveries are longer & more painful!*! ROP or LOP (sunny-side up) What nursing action could be performed? apply counter pressure

Breech Presentations

Occur in about 3% of all births Sacrum is landmark for breech births

Magnesium Sulfate for preterm labor

Other treatments while on Mag.: Draw Mag levels frequently Monitor for side effects of Mag Toxicity Watch _*VS*____ closely during loading dose & maintenance dose Commonly Used as Tocolytic CNS Depressant Relaxes Smooth Muscles Decreases calcium in cells

Causes of Hypotonic Pattern

Overdistension of uterus from: 🡹 AF, multiple gestation, multiparity Malpresentation CPD (cephalopelvic disproportion) Excessive narcotics, analgesics, anesthetics in early labor, esp before 3-4 cm dilation

Oxytocin Administration

Oxytocin hormone produced by posterior pituitary gland Used to either Induce or Augment labor *Contraindications*: Cephalopelvic disporportion (CPD) Prolapsed cord Transverse lie Placenta previa Prior classic uterine incision Active genital herpes infection Invasive cancer of cervix

Hypertonic Uterine Dysfunction

Painful, frequent, ineffective contractions Pain is out of proportion r/t effectiveness Contractions usually uncoordinated Usually occur when cervix is < 4 cm Force of contraction: midsection rather than fundus

FHR Decelerations

Periodic decreases in FHR from normal baseline Categorized as: *Early* *Late* *Variable*

A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. What should the nurse do first?

Place gentle pressure upward on the fetal head.

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately?

Place the client in a Trendelenburg position.

*U*terine Contractions development

Power is from _*fundus*__of uterus Contractions starts at top & sweep to bottom As contractions continue, top half of uterus becomes thicker & bottom half becomes thinner & more pliable

Carboprost tromethamine (Hemabate)

Preferred agent for controlling postpartum hemorrhage Causes intense uterine contractions Adverse effects GI reactions Vomiting and diarrhea Fever Vasoconstriction Constriction of the bronchi

Post Term Pregnancies

Pregnancy extends past end of week 42 294 days Clinical Manifestations: Maternal weight loss Decreased uterine size Meconium stained fluid Advanced bone maturation of fetal skeleton Exceptionally hard fetal skull

The nurse is caring for a primigravida client who has been admitted to the labor and birth unit. Assessment reveals fetal malpresentation, green amniotic fluid, and a fetal heart rate (FHR) of 98 beats/minute. What is the nurse's priority intervention?

Prepare for an emergency cesarean birth.

**engagement*_

Presenting part is settled into pelvis & is at level of ischial spines (zero station) Descent to this point means that pelvic inlet is adequate Does not guarantee that midcavity or outlet are adequate

Prolapsed Umbilical Cord

Prompt recognition is critical Fetal hypoxia > *5 minutes* can cause CNS damage or fetal death What will fetal monitor show with cord prolapse? Emergency! Occurs 1/400 deliveries If presenting part not engaged when ROM, cord can be carried downward

Reasons for Inducing Labor

Reasons for Inducing Labor: PIH or preeclampsia Diabetes Postdate gestation Suspected fetal jeopardy Dystocia Increased distance of woman's home from hospital

_*Station*_

Relationship of presenting part of fetus to level of ischial spines When presenting part is at level of ischial spine, it is at "0" station Above or below spines is measured in centimeters Minus 5 = head is floating Plus 5 = head is at the outlet

Fetal Presentation & Position: quadrants of the womens pelvis

Relationship of presenting part to a specific quadrant of woman's pelvis Three notations are used to describe fetal position Maternal Pelvis: Right or Left Landmark of fetal presenting Part Occiput = O Mentum = M Sacrum = S Scapula = Sc Maternal Pelvis Anterior, Posterior or Transverse

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor?

Remain in a side-lying position with the head elevated.

A client treated with terbutaline for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?

Report a heart rate greater than 120 beats/minute to the health care provider.

A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation?

Respect the adolescent's wishes and maintain her confidentiality.

Signs of Magnesium Toxicity

Respirations < 12 per minute Significant drop in maternal pulse/ blood pressure Hyporeflexia or absent reflexes Urine output < 30 ml/hour Serum mag levels > 9.6 4 - 7 is the therapeutic level Fetal tachycardia or bradycardia

Risks to infant &/ or mom: vacuum assisted

Risks to infant includes: Cephalhematoma Scalp lacerations Subdural hematoma Risks to mom includes: (rare) Perineal lacerations Vaginal lacerations Cervical lacerations

Preterm Premature Rupture of Membranes (PPROM)

Rupture of membranes before labor starts—at least 1 hour May be either gush or leak Risks of PPROM Chorioamnionitis: Potentially life threatening for mom & fetus Cord Prolapse Management—may attempt to prevent delivery

*Ruptured Membranes*

Rupture of membranes will occur sometime in 1st stage of labor Unless PROM *SROM* Spontaneous *AROM* Artificial What will you assess immediately? *Time, color, smell, amount, fetal response* What will you assess frequently? FHR & _*temperature* q2 hours

A school nurse is teaching a class about sexually transmitted infections (STIs). Which statement is correct regarding STIs?

STIs are most prevalent among teenagers and young adults.

Indomethacin (Indocin):tocolytic

Second-line tocolytic Inhibits prostaglandins NSAID Higher risk for neonatal complications Prolonged renal insufficiency, bronchopulmonary dysplasia, necrotizing enterocolitis, and periventricular leukomalacia

Variable Decelerations:

Sharp _*drop*__ from baseline & sharp return to baseline shoulders on the strip

Short Term vs Long Term Variability

Short Term Variability: Beat to Beat Only accurately measured with _*internal*__electrode Long Term Variability: Rhythmic Fluctuations

Anesthesia with Cesarean Births

Spinal Epidural Preferred by women They can be awake for birth of baby General Frequently used for emergent C-Sections

Second Stage of Labor

Starts at full dilation--verified with SVE Urge to push & bear down is very strong Uncontrollable urge This stage usually lasts: About 2 hours for Primiparas 15 minutes for Multiparas Fetal Descent: Cervix retracts over presenting part Baby descends through pelvis

Midline Episiotomy

Starts at posterior vaginal entrance & is directed straight back toward rectum *Advantage:* Heals more quickly Less blood loss Less discomfort

Mediolateral Episiotomy

Starts at same place Directed laterally away from rectum *Advantage:* If it tears, it won't tear into rectum

A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?

Stop the magnesium sulfate infusion.

*Nursing Management: Second Stage of Labor*

Support & Coach Help mom to "push" Assess well being of mom & baby Prepare mom for position of birth Assist with perineal cleansing Agency Protocol will determine procedure

*Episiotomy*

Surgical Incision made to prevent a tear Incision can either be a *Midline Episiotomy* *Mediolateral Episiotomy*

Beta2-selective adrenergic agonist: tocolytic

Terbutaline (Brethine) Beta2-selective adrenergic agonist Not approved by FDA for this use

Improper use of Pitocin can lead to....

Tetanic contractions Uterine rupture Trauma to mom and fetus if CPD exists

Critical Forces in Labor

The P's: Passageway Passenger Power Position of mother Psychological Factors

The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan?

The use of a condom is advised for sexual intercourse.

Cervical Changes: *Effacement*

Thinning & shortening of cervix Results from uterus "drawing up" internal os & cervical canal into side walls of uterus Cervix changes from being very thick, to paper thin Subjective assessment determines percentage of effacement Complete effacement is said to be 100% 50% effacement is about ½ inch thick

Systemic Narcotic Analgesic

This intervention has been declining Epidurals more commonly used Narcotics that can be administered.... Fentanyl, Dilaudid, Stadol, Nubain, Demerol.... Can be given IM or IV May cause fetal CNS depression May need to have Narcan available Premature babies cannot handle this effect

Electronic Monitoring: *Uterine* Contractions

Transducer detects pressure— Not always accurate Look for normal uterine activity pattern Contractions should occur every 2-5 minutes & should last less than 90 seconds Should have at least 30 seconds of rest from end of one contraction to beginning of next

*Fetal Heart Rate Measurement*

Transducer emits sound waves that bounce off of fetal heart Always compare maternal radial pulse with fetal heart rate Not always an accurate tracing due to movement & artifact

FHR Accelerations

Transient increases in heart rate normally caused by fetal movement & contractions Accelerations are a sign of fetal _*wellbeing*__ & adequate _*oxygen*_____ reserve

Shoulder Presentation

Transverse Lie All breech presentations will be delivered via _*c-section*_

Preoperative Preparation

Try to maintain a "Family Centered" Approach Preparation is similar to any abdominal surgery _*informed consent* __, pre-op history/ physical, lab work, nose to toes, foley catheter, removal of dentures, jewelry, fingernail polish........ Support person is encouraged to remain with woman if possible Nurse must provide support to support person & patient Especially for Emergent Cesareans Communicate as much as possible

Following an epidural and placement of internal monitors, a client's labor is augmented with oxytocin. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is >20 mm Hg with an abnormal fetal heart rate and pattern. Which action should the nurse take first?

Turn off the oxytocin infusion.

Magnesium Sulfate

Used as a tocolytic Book states that it is no longer a recommended drug for tocolysis Drug of choice to treat Preeclampsia/Eclampsia CNS Depressant Relaxes Smooth Muscles Decreases calcium in the cells Watch for side effects of Mag Toxicity!!

Modified Ritgen Maneuver

Used to control birth of head Attempt to prevent an episiotomy Hands are used to control head as it is born Provider will put pressure on perineum & guide during delivery

Uterine Relaxants (Tocolytics)

Used to delay delivery Average delay: only 48 hours If used with glucocorticoids, the glucocorticoids can accelerate lung development Also used to buy time to treat infection

*How to Deliver Placenta*

Usually takes about 5 minutes for delivery of placenta *Signs of Placental Separation:* Lengthening of umbilical _*cord*_ Slight gush of vaginal blood Change in shape of uterus *Expulsion of Placenta:* Mom starts to gently push Provider tugs gently

True Labor:

Uterine Contractions: Regular contractions Increase in frequency Increase in intensity Increase in duration Cause cervical _*dilation*_ & _*effacement*__ Do not decrease with walking, showering...

Tocolytics: Uterine relaxants

Uterine relaxation Suppression of preterm labor

Fetal Monitoring

What are we looking for? _*fetal* well-being Monitoring can be done "continuous" or "intermittent"

Sterile Vaginal Examinations (SVE):

What does nurse check for when doing a vaginal examination? NEVER DO if there is significant vaginal _*bleeding*_!! 1: centermeters dilated 2: percentatge. +/- effaced 3: fetal head in related to icial spine of the pelvis

Relationship of Fetal Skull with Pelvis

When fetus is entering pelvis, Biparietal Diameter (9.25 cm) of fetal skull must fit with anterior/posterior diameter (9.5-11.5cm) of pelvis.

The nurse is developing a community health education program about sexually transmitted infections. Which information about women who acquire gonorrhea should be included?

Women with gonorrhea are usually asymptomatic.

Signs & Symptoms of Impending Labor: cervix changes

_*cervix*__ Changes: Softening of cervix "Ripening" Collagen fibers are broken down Water content increases

Fetal Heart Rate range

_*fetal*_ heart rate in range of 110 - 160 beats per minute Document as a single number, not as a range Less than 110 is fetal bradycardia More than 160 is fetal tachycardia

*Uterine Contractions*3 steps*

_*frequency* Time between beginning of one contraction to beginning of next *Duration* Measured from beginning of contraction to completion _*Intensity* Strength of contraction

The nurse is speaking to a group of women about early detection of breast cancer. Which screening does the nurse recommend to women age 50 and older?

annual mammogram

A client with human papillomavirus (HPV) infection is being treated by a colposcopy. The client asks the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur?

cervical cancer

The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?

client at 38 weeks' gestation with active herpes lesions

A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred?

complete uterine rupture

Examination of a primigravid client having increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these findings as a response related to which factor?

control of the growth of pathologic bacteria

A full-term client is admitted for induction of labor. When admitted, her cervix is effaced 25% but has not dilated. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction?

dinoprostone

A 49-year-old woman has sought help from her primary care provider because of "intimacy problems." Upon questioning, the woman reveals that she is experiencing sexual desire, but that intercourse causes significant pain. In the absence of sexual activity, the woman states that she does not have any significant vaginal discomfort. What would the clinician recognize that this client is most likely experiencing?

dyspareunia

What should the nurse include in a community health program designed to control sexually transmitted infections (STIs)?

education about safe sex practices

An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate?

encouraging them to ask questions

A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important?

fetal heart rate

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a primary health care provider because the nurse suspects which sexually transmitted infection?

herpes genitalis

A sexually active male client has burning on urination and a milky discharge from the urethral meatus. What documentation should be included on the client's medical record? Select all that apply.

history of unprotected sex (sex without a condom) length of time since symptoms presented history of fever or chills presence of any enlarged lymph nodes on examination allergies to any medications

A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an IV infusion of oxytocin. Which aspect of the client's care plan should the nurse revise?

instructing the client to ambulate as tolerated

The nurse is interviewing a client with newly diagnosed syphilis. In order to prevent the spread of the disease, the focus of the interview should include which approach?

obtaining a list of the client's sexual contacts

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to

prevent seizures.

A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:

promote fetal lung maturity.

A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?

promoting adequate hydration

A couple seeks information about natural family planning. Which of the following should the nurse inform the couple about natural family planning? Select all that apply.

requires some period of abstinence uses calculations of menstrual cycles determines ovulation from basal body temperature

Which group has experienced the greatest rise in the incidence of sexually transmitted diseases (STDs) over the past two decades?

teenagers

A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. Which factor is most important for the nurse to assess next?

temperature.

A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the physician to order:

terbutaline.

A primigravid client at 32 weeks' gestation with ruptured membranes is prescribed to receive betamethasone 12 mg intramuscularly for two doses 24 hours apart. When teaching the client about the medication, what should the nurse include as the purpose of this drug?

to accelerate fetal lung maturity

variability: absent

undetectable

A young adult woman tells the nurse she has a slight yellow vaginal discharge. The nurse should tell the client to contact her health care provider if she has which additional symptoms? Select all that apply.

vaginal discharge that has a fishy odor abdominal pain a temperature above 101ºF (38.3ºC)