Nurse226 test 3 Week 9 chp 21 pages 729-740,

Diagnosis of excessive fetal size and abnormalities

A diagnosis of fetal macrosomia can be confirmed by measuring the birth weight after birth. Suspicion of macrosomia based on the findings of an ultrasound examination before onset of labor (if suspected due to conditions such as maternal diabetes or obesity, estimation of fetal weight via ultrasound). Leopold's maneuvers to estimate fetal weight and position on admission to labor and birth unit.

Precipitate labor

Abrupt onset of higher- intensity contractions occurring in a shorter period of time instead of the more gradual increase in frequency, duration, and intensity that typifies most spontaneous labors

Oxytocin (Pitocin)

Acts on uterine myofibrils to contract/to initiate or reinforce labor

Nursing implications for Oxytocin ( Pitocin) -

Administer as an IV infusion via pump, increasing dose based on protocol until adequate labor progress is achieved. Assess baseline vital signs and FHR and then frequently after initiating oxytocin infusion. Determine frequency, duration, and strength of contractions frequently. Notify health care provider of any uterine hypertonicity or abnormal FHR patterns. Maintain careful I&O, being alert for water intoxication. Keep client informed of labor progress. Monitor for possible adverse effects such as hyperstimulation of the uterus, impaired uterine blood flow leading to fetal hypoxia, rapid labor leading to cervical lacerations or uterine rupture, water intoxication (if oxytocin is given in electrolyte-free solution or at a rate exceeding 20 mU/min), and hypotension.

Nursing management of Hypotonic Uterine Dysfunction

Administer oxytocin as ordered once fetopelvic disproportion is ruled out. Assist with amniotomy if membranes are intact. Provide continuous electronic fetal monitoring. Monitor vital signs, contractions, and cervix continually. Assess for signs of maternal and fetal infection. Explain to woman and family about dysfunctional pattern. Plan for surgical birth if normal labor pattern is not achieved or fetal distress occurs.

Therapeutic mgmt of Multifetal pregnancy

Admission to facility with specialized care unit if woman goes into labor. Spontaneous progression of labor if woman has no complicating factors and first fetus is in longitudinal lie. Separate monitoring of each FHR during labor and birth. After birth of first fetus, clamping of cord and lie of the second twin assessed. Possible external cephalic version necessary to assist in providing a longitudinal lie. Second and subsequent fetuses at greater risk for birth- related complications, such as umbilical cord prolapse, malpresentation, and abruptio placentae. Cesarean birth if risk factors high.

antepartum assessment

Antepartum assessment for a prolonged pregnancy typically includes daily fetal movement counts done by the woman, nonstress tests done twice weekly, amniotic fluid assessments as part of the biophysical profile, and weekly cervical examinations to evaluate for ripening. In addition, assess the following: Client's understanding of the various fetal well-being tests Client's stress and anxiety concerning her lateness Client's coping ability and support network

Arrest disorders

Arrest disorders include secondary arrest of dilation (no progress in cervical dilation in more than 2 hours), arrest of descent (fetal head does not descend for more than 1 hour in primip and more than 0.5 hour in multip), and failure of descent (no descent). About 20% of labors involve either protraction or arrest disorders

Nursing mgmt of Breech presentation

Assess for associated conditions such as placenta previa, hydramnios, fetal anomalies, and multifetal pregnancy. Arrange for ultrasound to confirm fetal presentation. Assist with external cephalic version possible after 36 weeks and administer tocolytics to assist with external cephalic version. Anticipate trial labor for 4 to 6 hr to evaluate progress if version is unsuccessful. Plan for cesarean birth if no progress is seen or fetal distress occurs. After external cephalic version, administer RhoGAM to the Rh-negative woman to prevent a sensitization reaction if trauma has occurred and the potential for mixing of blood exists.

Nursing Mgmt of Persistent occiput posterior position

Assess for complaints of intense back pain in first stage of labor. Anticipate possible use of forceps to rotate to anterior position at birth or manual rotation to anterior position at end of second stage. Assess for prolonged second stage of labor with arrest of descent (common with this malposition). Encourage maternal position changes to promote fetal head rotation: hands and knees and rocking pelvis back and forth; side-lying position; side lunges during contractions; sitting, kneeling, or standing while leaning forward; squatting position to give birth and enlarge pelvic outlet. Prepare for possible cesarean birth if rotation is not achieved. Administer agents as ordered for pain relief (effective pain relief crucial to help the woman to tolerate the back discomfort). Apply low back counter pressure during contractions to ease the discomfort. Use other helpful measures to attempt to rotate the fetal head, including lateral abdominal stroking in the direction that the fetal head should rotate; assisting the client into a hands-and-knees position (all fours); and squatting, pelvic rocking, stair climbing, assuming a side-lying position toward the side that the fetus should rotate, and side lunges. Provide measures to reduce anxiety. Continuously reinforce the woman's progress. Teach woman about measures to facilitate fetal head rotation.

Nursing mgmt of Multifetal pregnancy

Assess for hypotonic labor pattern due to overdistention. Evaluate for fetal presentation, maternal pelvic size, and gestational age to determine mode of delivery. Ensure presence of neonatal team for birth of multiples. Anticipate need for cesarean birth, which is common in multifetal pregnancy.

Nursing mgmt of excessive fetal and abnormalities

Assess for inability of fetus to descend. Anticipate need for vacuum and forceps-assisted births (common). Plan for cesarean birth if maternal parameters are inadequate to give birth to large fetus.

Nursing mgmt of problems with the passageway

Assess for poor contractions, slow dilation, prolonged labor. Evaluate bowel and bladder status to reduce soft tissue obstruction and allow increased pelvic space. Anticipate trial of labor; if no labor progression after an adequate trial, plan for cesarean birth.

assessment of pt b4 admin of oxytocin -

Assist with determining the gestational age of the fetus to prevent a preterm birth. Assess fetal well-being to validate the client's and fetus's ability to withstand labor contractions. Evaluate the woman's cervical status, including cervical dilation and effacement, and station via vaginal examination as appropriate before cervical ripening or induction is started. Determine the Bishop score to determine the probable success of induction.

Nursing Mgmt of Face and brow presentation

Assist with evaluating for fetopelvic disproportion. Anticipate cesarean birth if vertex position is not achieved. Explain fetal malposition to the woman and her partner. Provide close observation for any signs of fetal hypoxia, as evidenced by late decelerations on the fetal monitor.

Before labor induction is started

Before labor induction is started, fetal maturity (dating, ultrasound, amniotic fluid studies) and cervical readiness (vaginal examination, Bishop scoring; see Table 21.2) must be assessed. Both need to be favorable for a successful induction.

Various scoring systems to assess cervical ripeness have been introduced, but the __________ is most commonly used today.

Bishop score

Diagnosis of Hypertonic uterine dysfunction

Characteristic hypertonicity of the contractions and the lack of labor progress

Therapeutic management of umbilical cord compression between the fetal body and the maternal pelvis

Clear room of unnecessary clutter to make room for additional personnel and equipment. After the birth, assess newborn for crepitus, deformity, Erb's palsy, or bruising, which might suggest neurologic damage or a fracture.

Nursing Mgmt of Precipitate Labor

Closely monitor woman with previous history. Anticipate use of scheduled induction to control labor rate. Administer pharmacologic agents, such as tocolytics, to slow labor. Stay in constant attendance to monitor progress.

Diagnosis of umbilical cord compression between the fetal body and the maternal pelvis

Combination of maneuvers effective in more than 50% of cases of shoulder dystocia Newborn resuscitation team readily available.

Complete breech ( or full breech)

Complete breech (or full breech): buttock as presenting part, with hips flexed and knees flexed in a "cannonball" position

_____________ - essential for the woman who wants to have a trial of labor after cesarean birth. The client must be advised about the risks as well as the benefits. She must understand the ramifications of uterine rupture, even though the risk is small.

Consent: Fully informed consent

When a pt is getting oxytocin Monitor FHR and document it every ___ minutes during the _____ phase of labor and Every ____ minutes during the second stage during the _______ phase.

Continue to monitor the FHR continuously and document it every 15 minutes during the active phase of labor and every 5 minutes during the second stage. Assist with pushing efforts during the second stage.

Problems with the Passageway

Contraction of one or more of the three planes of the pelvis. Poorer prognosis for vaginal birth in women with android and platypelloid types of pelvis. Contracted pelvis involving reduction in one or more of the pelvic diameters interfering with progress of labor: inlet, midpelvis, and outlet contracture. Obstruction in the birth canal, such as placenta previa that partially or completely obstructs the internal os of the cervix, fibroids in the lower uterine segment, a full bladder or rectum, an edematous cervix caused by premature bearing-down efforts, and human papillomavirus (HPV) warts.

Shoulder dystocia

Delivery of fetal head with neck not appearing; retraction of chin against the perineum; shoulders remaining wedged behind the mother's pubic bone, causing a difficult birth with potential for injury to both mother and baby. If shoulders still above the brim at this stage, no advancement. Newborn's chest trapped within the vaginal vault; chest unable to expand with respiration (although nose and mouth are outside).

Diagnosis of Face and brow presentation

Diagnosis only once labor is well established via vaginal examination; palpation of facial features as the presenting part rather than the fetal head

Dinoprostone (Cervidil insert; Prepidil gel) -

Directly softens and dilates the cervix/to ripen cervix and induce labor FDA approved for cervical ripening

Providing Care During the Intrapartum Period .

During the intrapartum period, continuously assess and monitor FHR to identify potential fetal distress early (e.g., late or variable decelerations) so that interventions can be initiated. Also monitor the woman's hydration status to ensure maximal placental perfusion. When the membranes rupture, assess amniotic fluid characteristics (color, amount, and odor) to identify previous fetal hypoxia and prepare for prevention of meconium aspiration. Report meconium-stained amniotic fluid immediately when the membranes rupture. Anticipate the need for amnioinfusion to minimize the risk of meconium aspiration by diluting the meconium in the amniotic fluid expelled by the hypoxic fetus. In addition, monitor the woman's labor pattern closely because dysfunctional patterns are common

expulsive forces

Dystocia can result from problems or abnormalities involving the expulsive forces (known as the "powers"); presentation, position, and fetal development (the "passenger"); the maternal bony pelvis or birth canal (the "passageway"); and maternal stress (the "psyche

Dystocia can result from problems or abnormalities involving the expulsive forces

Dystocia can result from problems or abnormalities involving the expulsive forces (known as the "powers"); presentation, position, and fetal development (the "passenger"); the maternal bony pelvis or birth canal (the "passageway"); and maternal stress.

Diagnosis of Shoulder dystocia

Emergency, often unexpected complication. Diagnosis made when newborn's head delivers without delivery of neck and remaining body structures.

Providing Physical and Emotional Comfort

Employ physical comfort measures to promote relaxation and reduce stress. Offer blankets for warmth and a backrub, if the client wishes, to reduce muscle tension. Provide an environment conducive to rest so the woman can conserve her energy. Lower the lights and reduce external noise by closing the hallway door. Offer a warm shower to promote relaxation (if not contraindicated). Use pillows to support the woman in a comfortable position, changing her position every 30 minutes to reduce tension and to enhance uterine activity and efficiency. Offer her fluids/food as appropriate to moisten her mouth and replenish her energy

Persistent occiput posterior position

Engagement of fetal head in the left or right occipito-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position (fetus born facing upward instead of the normal downward position) Labor usually much longer and more uncomfortable (causing increased back pain during labor) if fetus remains in this position. Possible extensive caput succedaneum and molding from the sustained occiput posterior position.

Diagnosis of Hypotonic Uterine Dysfunction

Evaluation of the woman's labor to confirm that she is having hypotonic active labor rather than a long latent phase. Evaluation of maternal pelvis and fetal presentation and position to ensure that they are not contributing to the prolonged labor without noticeable progress.

Face and brow presentation

Face presentation with complete extension of the fetal head. Brow presentation: fetal head between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis.

Breech presentation

Fetal buttocks, or breech, presenting first rather than the head. Frank breech: buttock as the presenting part, with hips flexed and legs and knees extended upward Complete breech (or full breech): buttock as presenting part, with hips flexed and knees flexed in a "cannonball" position Footling or incomplete breech: One or two feet as the presenting part, with one or both hips extended

Therapeutic mgmt of problems with the passageway

Focus on allowing natural forces of labor contractions to push the largest diameter (biparietal) of the fetal head beyond the obstruction or narrow passage. Possible forceps and vacuum extraction to assist navigation through this passageway.

Footing or incomplete breech

Footling or incomplete breech: One or two feet as the presenting part, with one or both hips extended

Frank breech

Frank breech: buttock as the presenting part, with hips flexed and legs and knees extended upward

assessment of Uterine rupture -

Generally, the first and most reliable symptom of uterine rupture is sudden fetal distress. Other signs may include acute and continuous abdominal pain with or without an epidural, vaginal bleeding, hematuria, irregular abdominal wall contour, loss of station in the fetal presenting part, and hypovolemic shock in the woman, fetus, or both (Nahum & Pham, 2011). Timely management of uterine rupture depends on prompt detection. Because many women desire a trial of labor after a previous cesarean birth, the nurse must be familiar with the signs and symptoms of uterine rupture. It is difficult to prevent uterine rupture or to predict which women will experience rupture, so constant preparedness is necessary. Screening all women with previous uterine surgical scars is important, and continuous electronic fetal monitoring should be used during labor because this may provide the only indication of an impending rupture

___________ absorb endocervical and local tissue fluids; as they enlarge, they expand the endocervix and provide controlled mechanical pressure.

Hygroscopic dilators

Hypertonic uterine dysfunction

Hypertonic uterine dysfunction occurs when the uterus never fully relaxes between contractions. Subsequently, contractions are erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Contractions are ineffectual, erratic, uncoordinated, and involve only a portion of the uterus. Women in this situation experience a prolonged latent phase, stay at 2 to 3 cm, and do not dilate as they should. Placental perfusion becomes compromised, thereby reducing oxygen to the fetus. These hypertonic contractions exhaust the mother, who is experiencing frequent, intense, and painful contractions with little progression. This dysfunctional pattern occurs in early labor and affects nulliparous women more than multiparous women (Walsh, Foley, & O'herlihy, 2011).

Hypotonic uterine dysfunction

Hypotonic uterine dysfunction occurs during active labor (dilation more than 4 cm) when contractions become poor in quality and lack sufficient intensity to dilate and efface the cervix. Factors associated with this abnormal labor pattern include overstretching of the uterus, a large fetus, multiple fetuses, hydramnios, multiple parity, bowel or bladder distention preventing descent, and excessive use of analgesia. Clinical manifestations of hypotonic uterine dysfunction include weak contractions that become milder, a uterine fundus that can be easily indented with fingertip pressure at the peak of each contraction, and contractions that become more infrequent and briefer (Joy et al., 2011). The major risk with this complication is hemorrhage after giving birth because the uterus cannot contract effectively to compress blood vessels.

Diagnosis of Precipitate Labor

Identification based on the rapidity of progress through the stages of labor

Therapeutic Mgmt of Hypotonic Uterine Dysfunction

Identification of possible cause of inefficient uterine action (a malpositioned fetus, a too small maternal pelvis, overdistention of the uterus with fluid or a macrosomic fetus). Rupture of amniotic sac (amniotomy) if all causes ruled out. Possible augmentation with oxytocin (Pitocin) to stimulate effective uterine contractions. Cesarean birth if amniotomy and augmentation ineffective.

Therapeutic Mgmt of Shoulder dystocia

If anticipated, preparatory tasks instituted: alerting of key personnel; education of woman and family regarding steps to be taken in the event of a difficult birth; emptying of woman's bladder to allow additional room for possible maneuvers needed for the birth. McRobert's maneuver. Suprapubic pressure (not fundal) (see Fig. 21.1).

Administering Oxytocin

If not already done, prepare the oxytocin infusion by diluting 10 units of oxytocin in 1,000 mL of lactated Ringer's solution or ordered isotonic solution. Use an infusion pump on a secondary line connected to the primary infusion. Start the oxytocin infusion in mU/min or milliliters per hour as ordered. Each hospital has its own standards/protocols for oxytocin infusion and dilution. The nurse needs to follow that procedure when administering this medication. Maintain the rate once the desired contraction frequency has been reached. To ensure adequate maternal and fetal surveillance during induction or augmentation, the nurse-to-client ratio should not exceed 1:2

side effects of inductions using oxytocin -

Induction using oxytocin has side effects (water intoxication, hypotension, and uterine hypertonicity), but because the drug does not cross the placental barrier, no direct fetal problems have been observed

Nursing Mgmt of Hypertonic uterine dysfunction

Institute bed rest and sedation to promote relaxation and reduce pain. Assist with measures to rule out fetopelvic disproportion and fetal malpresentation. Evaluate fetal tolerance to labor pattern, such as monitoring of FHR patterns. Assess for signs of maternal infection. Promote adequate hydration through IV therapy. Provide pain management via epidural or IV analgesics. Assist with amniotomy to augment labor. Explain to woman and family about dysfunctional pattern. Plan for operative birth if normal labor pattern is not achieved.

Nursing implications of Misoprostol (Cytotec) -

Instruct client about purpose and possible adverse effects of medication. Ensure informed consent is signed per hospital policy. Assess vital signs and FHR patterns frequently. Monitor client's reaction to drug. Initiate oxytocin for labor induction at least 4 hours after last dose was administered. Monitor for possible adverse effects such as nausea and vomiting, diarrhea, uterine hyperstimulation, and category II and II FHR patterns.

Nursing mgmt of Shoulder dystocia

Intervene immediately due to cord compression. Perform McRobert's maneuver and application of suprapubic pressure. Assist with positioning the woman in squatting position, hands-and-knees position, or lateral recumbent position for birth to free shoulder. Anticipate cesarean birth if no success in dislodging shoulders.

Signs and symptoms of Uterine rupture -

Its onset is often marked only by sudden fetal bradycardia, and treatment requires rapid surgery for good outcomes. From the time of diagnosis to delivery, only 10 to 30 minutes are available before clinically significant fetal morbidity occurs. Fetal morbidity occurs secondary to catastrophic hemorrhage, fetal anoxia, or both.

Normal labor vs. abnormal

Labor refers to uterine contractions resulting in progressive dilation and effacement of the cervix, and accompanied by descent and expulsion of the fetus. Abnormal labor, dystocia, and failure to progress are imprecise terms that have been used to describe a difficult labor pattern that deviates from that observed in the majority of women who have spontaneous vaginal deliveries. A better classification is to characterize labor abnormalities as protraction disorders (i.e., slower than normal progress) or arrest disorders (i.e., complete cessation of progress).

Therapeutic Mgmt of Persistent occiput posterior position

Labor to proceed, preparing the woman for a long labor (spontaneous resolution possible). Comfort measures and maternal positioning to help promote fetal head rotation.

Diagnosis of Persistent occiput posterior position

Leopold maneuvers and vaginal examination to determine position of fetal head in conjunction with the mother's complaints of severe back pain (back of fetal head pressing on mother's sacrum and coccyx).

Excessive fetal size and abnormalities can also contribute to labor and birth dysfunctions

Macrosomia

Excessive fetal size and abnormalities

Macrosomia leading to fetopelvic disproportion (fetus unable to fit through the maternal pelvis to be born vaginally). Reduced contraction strength due to overdistention by large fetus leading to a prolonged labor and the potential for birth injury and trauma. Fetal abnormalities possibly interfering with fetal descent, leading to prolonged labor and difficult birth.

Generally, the first and most reliable symptom of uterine rupture is sudden fetal distress. Other signs may include acute and continuous abdominal pain with or without an epidural, vaginal bleeding, hematuria, irregular abdominal wall contour, loss of station in the fetal presenting part, and hypovolemic shock in the woman, fetus, or both (Nahum & Pham, 2011). Timely management of uterine rupture depends on prompt detection. Because many women desire a trial of labor after a previous cesarean birth, the nurse must be familiar with the signs and symptoms of uterine rupture. It is difficult to prevent uterine rupture or to predict which women will experience rupture, so constant preparedness is necessary. Screening all women with previous uterine surgical scars is important, and continuous electronic fetal monitoring should be used during labor because this may provide the only indication of an impending rupture

Maternal death is a real possibility without rapid intervention. Newborn outcome after rupture depends largely on the speed with which surgical rescue is carried out. As in any case of acute obstetric emergency, preparation and timely mobilization of all necessary personnel is key to optimizing outcome. When excessive bleeding occurs during the childbirth process and it persists or signs such as bruising or petechiae appear, disseminated intravascular coagulation (DIC) should be suspected

Signs and symptoms of Placenta previa -

Maternal signs and symptoms of placenta previa include sudden, painless bleeding (that may be heavy enough to be considered hemorrhaging), anemia, pallor, hypoxia, low blood pressure, tachycardia, soft and nontender uterus, and rapid, weak pulse. Bleeding may be episodic, with spontaneous initiation and cessation; in some cases, it is asymptomatic.

Multifetal pregnancy

More than one fetus, leading to uterine overdistention and possibly resulting in hypotonic contractions and abnormal presentations of the fetuses. Fetal hypoxia during labor a significant threat due to placenta providing oxygen and nutrients to more than one fetus.

Diagnosis of Multifetal pregnancy

Nearly all multiples are now diagnosed early by ultrasound. Most women go into labor before 37 weeks.

Most common injuries in newborns with shoulder dystocia

Newborns experiencing shoulder dystocia typically have greater shoulder-to-head and chest-to-head disproportions compared with those delivered without dystocia (Cunningham et al., 2010). Prompt recognition and appropriate management, such as

Nursing Assessment

Obtain a thorough history to determine the estimated date of birth. Many women are unsure of the date of their last menstrual period, so the date given may be unreliable. Despite numerous methods used to date pregnancies, many are still misdated. Accurate gestational dating via ultrasound is essential

Hypertonic uterine dysfunction

Occurring in the latent phase of the first stage of labor (cervical dilation of <4 cm); uncoordinated. Force of contraction typically in the midsection of uterus at the junction of the active upper and passive lower segments of the uterus rather than in the fundus. Loss of downward pressure to push the presenting part against the cervix Woman commonly becomes discouraged due to lack of progress; also has increased pain secondary to uterine anoxia.

Hypotonic Uterine Dysfunction

Often termed secondary uterine inertia because the labor begins normally and then the frequency and intensity of contractions decrease. Possible contributing factors: overdistended uterus with multifetal pregnancy or large single fetus, too much pain medicine given too early in labor, fetal malposition, and regional anesthesia

Hypotonic uterine dysfunction

Often termed secondary uterine inertia because the labor begins normally and then the frequency and intensity of contractions decrease. Possible contributing factors: overdistended uterus with multifetal pregnancy or large single fetus, too much pain medicine given too early in labor, fetal malposition, and regional anesthesia

Oxytocin has many advantages:

Oxytocin has many advantages: it is potent and easy to titrate, it has a short half-life (1 to 5 minutes), and it is generally well tolerated.

Oxytocin is administered via an -

Oxytocin is administered via an intravenous infusion pump piggybacked into the main intravenous line at the port most proximal to the insertion site. Typically 10 units of oxytocin is added to 1 L of isotonic solution. The dose is titrated according to protocol to achieve stable contractions every 2 to 3 minutes lasting 40 to 60 seconds (Gittinger & Abbott, 2011). The uterus should relax between contractions. If the resting uterine tone remains above 20 mm Hg, uteroplacental insufficiency and fetal hypoxia can result. This underscores the importance of continuous FHR monitoring. Unfortunately, neither the optimal oxytocin administration regimen nor the maximum oxytocin dose has been established through research or agreed-on expert opinion. Nurses assisting with labor inductions need to become familiar with their hospital protocols concerning dosage, infusion rates, and frequency of change.

the most common malposition, occurring in about 15% of laboring women

Persistent occiput posterior

Placental Abruption Placental abruption refers to premature separation of a normally implanted placenta from the maternal myometrium

Placental abruption refers to premature separation of a normally implanted placenta from the maternal myometrium

In shoulder dystocia - the major complication to the mother

Postpartum hemorrhage, secondary to uterine atony or vaginal lacerations

Precipitate Labor

Precipitate labor is labor that is completed in less than 3 hours from the start of contractions to birth. A nullipara's cervix dilates faster than 5 cm per hour or the fetal head descends faster than 1 cm per 12 minutes. A multipara's cervix dilates faster than 10 cm per hour or the fetal head descends faster than 1 cm per 6 minutes (Gilbert, 2011). Women experiencing precipitate labor typically have soft perineal tissues that stretch readily, permitting the fetus to pass through the pelvis quickly, or abnormally strong uterine contractions. Maternal complications are rare if the maternal pelvis is adequate and the soft tissues yield to a fast fetal descent. However, if the fetus delivers too fast, it does not allow the cervix to dilate and efface, which leads to cervical lacerations and the potential for uterine rupture. Potential fetal complications may include head trauma, such as intracranial hemorrhage or nerve damage, and hypoxia due to the rapid progression of labor (Barss, 2011). Precipitate labor is an anxiety-producing situation and frequently very painful with little rest between contractions. Continuous monitoring, frequent updates on her labor progress, pain management and reassurance about her condition can assist in reducing the mother's anxious state of mind. Management includes readiness of the health care team for this rapid birth.

umbilical cord prolapse nursing assessment -

Prevention is the key to managing cord prolapse by identifying clients at risk for this condition. Carefully assess each client to help predict her risk status. Be aware that cord prolapse is more common in pregnancies involving malpresentation, growth restriction, prematurity, ruptured membranes with a fetus at a high station, hydramnios, grandmultiparity, and multifetal gestation (Cunningham et al., 2010). Continuously assess the client and fetus to detect changes and to evaluate the effectiveness of any interventions performed.

Risk of umbilical cord compression between the fetal body and the maternal pelvis.

Primary risk factors, including suspected infant macrosomia (weight >4,500 g), maternal diabetes mellitus, excessive maternal weight gain, abnormal maternal pelvic anatomy, maternal obesity, postdated pregnancy, short stature, a history of previous shoulder dystocia, and use of epidural analgesia

patho/phys of umbilical cord prolapse -

Prolapse usually leads to total or partial occlusion of the cord. Since this is the fetus's only lifeline, fetal perfusion deteriorates rapidly. Complete occlusion renders the fetus helpless and oxygen deprived. The fetus will die if the cord compression is not relieved.

nursing management of umbilical cord prolapse

Prompt recognition of a prolapsed cord is essential to reduce the risk of fetal hypoxia resulting from prolonged cord compression. When membranes are artificially ruptured, assist with verifying that the presenting part is well applied to the cervix and engaged into the pelvis. If pressure or compression of the cord occurs, assist with measures to relieve the compression. Typically, the examiner places a sterile gloved hand into the vagina and holds the presenting part off the umbilical cord until delivery. Changing the woman's position to a modified Sims, Trendelenburg, or knee-chest position also helps relieve cord pressure. Monitor fetal heart rate, maintain bed rest, and administer oxygen if ordered. Provide emotional support and explanations as to what is going on to allay the woman's fears and anxiety. If the mother's cervix is not fully dilated, prepare the woman for an emergency cesarean birth to save the fetus's life.

Nursing mgmt of problems with the Psyche

Provide comfortable environment—dim lighting, music. Encourage partner to participate. Provide pain management to reduce anxiety and stress. Ensure continuous presence of staff to allay anxiety. Provide frequent updates concerning fetal status and progress. Provide ongoing encouragement to minimize the woman's stress and help her to cope with labor and to promote a positive, timely outcome. Assist in relaxation and comfort measures to help her body work more effectively with the forces of labor. Engage the woman in conversation about her emotional well-being; offer anticipatory guidance and reassurance to increase her self-esteem and ability to cope, decrease frustration, and encourage cooperation.

Nursing implications of Dinoprostone (Cervidil insert; Prepidil gel -

Provide emotional support. Administer pain medications as needed. Frequently assess degree of effacement and dilation. Monitor uterine contractions for frequency, duration, and strength. Assess maternal vital signs and FHR pattern frequently. Monitor woman for possible adverse effects such as headache, nausea and vomiting, and diarrhea.

Pt taking Oxytocin Patient assessment -

Providing Pain Relief and Support Assess the woman's level of pain. Ask her frequently to rate her pain and provide pain management as needed. Offer position changes and other nonpharmacologic measures. Note her reaction to any medication given, and document its effect. Monitor her need for comfort measures as contractions increase. Throughout induction and augmentation, frequently reassure the woman and her partner about the fetal status and labor progress. Provide them with frequent updates on the condition of the woman and the fetus. Assess the woman's ability to cope with stronger contractions (Simpson, 2010). Provide support and encouragement as indicated.

Problems with the Psyche

Release of stress-related hormones (catecholamines, cortisol, epinephrine, beta-endorphin), which act on smooth muscle (uterus) and reduce uterine contractility. Excessive release of catecholamines and other stress-related hormones not therapeutic. Release also results in decreased uteroplacental perfusion and increased risk for poor newborn adjustment.

occurrence and risk factors for Placenta previa -

Reported incidence is approximately 1 in 200 births (March of Dimes, 2011b). There is a direct relationship between the number of previous cesarean births and the risk of placenta previa, probably due to uterine scarring. The degree of occlusion of the internal cervical os may depend on the degree of cervical dilation, so what may appear to be a low-lying or marginal placenta previa prior to the onset of labor can progress to become more serious as the cervix effaces and opens up

Misoprostol (Cytotec)

Ripens cervix/to induce labor

Risk Factors of Placental Abruption -

Risk factors include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology. These conditions may force blood into the underlayer of the placenta and cause it to detach

risk factors assoc with amniotomy -

Risks associated with these procedures include umbilical cord prolapse or compression, maternal or neonatal infection, FHR deceleration, bleeding, and client discomfort

Diagnosis of problems with the Psyche

Ruling out of other possible causes of dystocia

Therapeutic mgmt of excessive fetal and abnormalities

Scheduled cesarean birth if diagnosis is made before the onset of labor to reduce the risk of injury to both the newborn and the mother. If identified by Leopold's maneuvers, possible trial of labor to evaluate progress; however, providers usually opt to proceed with a cesarean birth in a primigravida with a macrosomic fetus.

Diagnosis of problems with the passageway

Shortest A-P diameter <10 cm or greatest transverse diameter <12 cm. (Approximation of A-P diameter via measurement of diagonal conjugate, which in the contracted pelvis is <11.5 cm.) X-ray pelvimetry to determine the smallest A-P diameter through which the fetal head must pass. Interischial tuberous diameter of <8 cm possibly compromising outlet contracture (outlet and midpelvic contractures frequently occur together).

Multifetal pregnancy most common issues

The most common maternal complication is postpartum hemorrhage resulting from uterine atony.

Therapeutic Mgmt of Breech presentation

The optimal method of birth is controversial: cesarean birth by some providers unless the fetus is small and the mother has a large pelvis; vaginal birth by others with each occurrence treated individually and labor monitored very closely. Regardless of the birth method selected, the risk for trauma is high. Breech vaginal births are not recommended by ACOG and come with a higher risk to the mother and infant than a planned surgical birth. Vaginal delivery: fetus allowed to spontaneously deliver up to the umbilicus; then maneuvers to assist in the delivery of the remainder of the body, arms, and head; fetal membranes left intact as long as possible to act as a dilating wedge and to prevent cord prolapse; anesthesiologist and pediatrician present. Cesarean birth; use of external cephalic version to reduce the chance of breech presentation at birth; attempted after the 36th week of gestation but before the start of labor (some fetuses spontaneously turn to a cephalic presentation on their own toward term, and some will return to the breech presentation if external cephalic version is attempted too early; variable success rates, with risk for fractured bones, ruptured viscera, abruptio placentae, fetomaternal hemorrhage, and umbilical cord entanglement. Tocolytic drugs to relax the uterus, as well as other methods, to facilitate external cephalic version at term. Individual evaluation of each woman for all factors before any interventions are initiated.

Protracted disorders

The term protracted disorders refers to a series of events including protracted active phase dilation (slower than normal rate of cervical dilation) and protracted descent (delayed descent of the fetal head in the active phase). A laboring woman who has a slower than normal rate of cervical dilation is said to have a protraction labor pattern disorder. In terms of time, it describes a labor lasting more than 18 to 24 hours. Diagnostic criteria are 1.2 cm per hour for primips and 1.5 cm per hour for multips. For protracted descent, the criteria are less than 1.0 cm per hour in primips and less than 2.0 cm per hour for multips. A slow progress may be the result of cephalopelvic disproportion (CPD). Most women, however, benefit greatly from adequate hydration and some nutrition, emotional reassurance, and position changes—these women may go on and give birth vaginally.

VBAC and cervical ripening agents ?

The use of cervical ripening agents increases the risk of uterine rupture and thus is contraindicated in VBAC clients.

Therapeutic Mgmt of Hypertonic uterine dysfunction

Therapeutic rest with the use of sedatives to promote relaxation and stop the abnormal activity of the uterus. Identification and intervention of any contributing factors. Ruling out abruptio placentae (also associated with high resting tone and persistent pain). Onset of a normal labor pattern occurs in many women after a 4- to 6-hr rest period.

diagnosis of Placenta previa -

This position can create a barrier for the fetus from the uterus during the birthing process. As the cervix begins to thin and dilate (open up) in preparation for labor, blood vessels that connect the placenta to the uterus may tear and cause bleeding. It is the most common cause of bleeding in the second half of pregnancy and should be suspected in any woman beyond 24 weeks' gestation presenting with vaginal bleeding; ultrasonography (e.g., transvaginal) is used to diagnose it. During labor and birth, bleeding can be severe, which can place the mother and fetus at risk.

Persistent occiput posterior presents -

This position presents slightly larger diameters to the maternal pelvis, thus slowing fetal descent. A fetal head that is poorly flexed may be responsible. In addition, poor uterine contractions may not push the fetal head down into the pelvic floor to the extent that the fetal occiput sinks into it rather than being pushed to rotate in an anterior direction.

Throughout labor

Throughout labor, assess the woman's fluid balance status. Check skin turgor and mucous membranes. Monitor intake and output. Also monitor the client's bladder for distention at least every 2 hours and encourage her to empty her bladder often. In addition, monitor her bowel status. A full bladder or rectum can impede descent. Continue to monitor fetal well-being. If the fetus is in the breech position, be especially observant for visible cord prolapse and note any variable decelerations in heart rate. If either occurs, report it immediately. Be prepared to administer a labor stimulant such as oxytocin (Pitocin) if ordered to treat hypotonic labor contractions. Anticipate the need to assist with manipulations if shoulder dystocia is diagnosed. Prepare the woman and her family for the possibility of a cesarean birth if labor does not progress.

In shoulder dystocia - most common fetal injuries encountered with shoulder dystocia

Transient Erb's or Duchenne's brachial plexus palsies and clavicular or humeral fractures

Therapeutic mgmt of problems with the Psyche

Treatment dependent on woman's responses such as anxiety, fear, anger, frustration, or denial (highly variable due to woman's understanding of the condition itself, past experiences, previous coping mechanisms, and the amount of family and nursing support received). Appropriate medical or surgical interventions depending on the underlying condition.

VBAC -

Vaginal birth after cesarean (VBAC) describes a woman who gives birth vaginally after having at least one previous cesarean birth. Despite evidence that some women who have had a cesarean birth are candidates for vaginal birth, most women who have had a cesarean birth once undergo another for subsequent pregnancies

Therapeutic Mgmt of Face and brow presentation

Vaginal birth possible with face presentation with an adequate maternal pelvis and fetal head rotation; cesarean birth if head rotates backward. Cesarean birth for brow presentation unless head flexes.

Therapeutic Mgmt of Precipitate Labor

Vaginal delivery if maternal pelvis is adequate

Diagnosis of Breech presentation

Vaginal examination to determine breech presentation. Ideally, ultrasound to confirm a clinically suspected presentation and to identify any fetal anomalies.

Any time amniotomy or stripping of the membranes is done the nurse needs to -

When either of these techniques is used, amniotic fluid characteristics (such as whether it is clear or bloody, or meconium is present) and the FHR pattern must be monitored closely.

taking note umbilical cord prolapse

When the presenting part does not fully occupy the pelvic inlet, prolapse is more likely to occur.

Uterine rupture is a

a catastrophic tearing of the uterus at the site of a previous scar into the abdominal cavity.

Bishop scores of less than 6 usually indicate that - .

a cervical ripening method should be used prior to induction

Bishop score: a score over 8 indicates -

a successful vaginal birth.

The Bishop score helps identify women who would be most likely to -

achieve a successful induction (Table 21.2). The duration of labor is inversely correlated with the Bishop score:

The decision to induce labor is based on a thorough evaluation of maternal and fetal status. Typically, this includes

an ultrasound to evaluate fetal size, position, and gestational age and to locate the placenta; engaged presenting fetal part; pelvimetry to rule out fetopelvic disproportion; a nonstress test to evaluate fetal well-being; a phosphatidylglycerol (PG) level to assess fetal lung maturity; Nitrazine paper and/or fern test to confirm ruptured membranes; complete blood count and urinalysis to rule out infection; and a vaginal examination to evaluate the cervix for inducibility (ACOG, 2009b). Accurate dating of the pregnancy also is essential before cervical ripening and induction are initiated to prevent a preterm birth

Contraindications to labor induction include

complete placenta previa, abruptio placentae, transverse fetal lie, prolapsed umbilical cord, a prior classic uterine incision that entered the uterine cavity, pelvic structure abnormality, previous myomectomy, vaginal bleeding with unknown cause, invasive cervical cancer, active genital herpes infection, and abnormal FHR patterns

contraindications of oxytocin -

contraindications such as placenta previa, overdistended uterus, active genital herpes, fetopelvic disproportion, fetal malposition, or severe fetal distress

_______ is the only drug that is approved by the FDA for use as a cervical ripening agent, although ACOG acknowledges the apparent safety and effectiveness of misoprostol for this purpose

dinoprostone

Prostaglandin analogs commonly used for cervical ripening include -

dinoprostone gel (Prepidil), dinoprostone inserts (Cervidil), and misoprostol (Cytotec). Misoprostol (Cytotec), a synthetic PGE1 analog, is a gastric cytoprotective agent used in the treatment and prevention of peptic ulcers. It can be administered intravaginally or orally to ripen the cervix or induce labor. It is available in 100-mcg or 200-mcg tablets, but doses of 25 to 50 mcg are typically used

Labor augmentation

enhances ineffective contractions after labor has begun. Continuous electronic FHR monitoring is necessary.

Complications associated with dystocia related to excessive fetal size and anomalies include an increased risk for

fetal size and anomalies include an increased risk for postpartum hemorrhage, dysfunctional labor, fetopelvic disproportion, soft tissue laceration during vaginal birth, fetal injuries or fractures, and asphyxia (Joy et al., 2011).

oxytocin has an antidiuretic effect, resulting in decreased urine flow that may lead to water intoxication. Symptoms to watch for include headache and vomiting.

for include headache and vomiting.

Cytotec is contraindicated in

for women with prior uterine scars and therefore should not be used for cervical ripening in women attempting a vaginal birth after cesarean.

Management of placental abruption depends on the

gestational age, the extent of the hemorrhage, and maternal-fetal oxygenation perfusion/reserve status (see Chapter 19 for additional information on abruptio placentae). Treatment is based on the circumstances. Typically once the diagnosis is established, the focus is on maintaining the cardiovascular status of the mother and developing a plan to deliver the fetus quickly. A cesarean birth may take place quickly if the fetus is still alive with only a partial abruption. A vaginal birth may take place if there is fetal demise secondary to a complete abruption

Nonpharmacologic methods for cervical ripening are less frequently used today, but nurses need to be aware of them and question clients about their use. Methods may include

herbal agents such as evening primrose oil, black haw, black and blue cohosh, and red raspberry leaves. In addition, castor oil, hot baths, and enemas are used for cervical ripening and labor induction. The risks and benefits of these agents are unknown. None have been evaluated scientifically, and thus, none can be recommended regarding their efficacy or safety

A major adverse effect of the obstetric use of Cytotec is

hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism

Macrosomia

in which a newborn weighs 4,000 to 4,500 g (8.13 to 9.15 lb) or more at birth, complicates approximately 10% of all pregnancies

Contraindications of VBAC -

include a prior classic uterine incision, prior transfundal uterine surgery (myomectomy), uterine scar other than low-transverse cesarean scar, contracted pelvis, and inadequate staff or facility if an emergency cesarean birth in the event of uterine rupture is required

The risks associated with these methods include

include infection, bleeding, membrane rupture, and placental disruption For example, an indwelling (Foley) catheter (e.g., 26 French) can be inserted into the endocervical canal to ripen and dilate the cervix. The catheter is placed in the uterus, and the balloon is filled. Direct pressure is then applied to the lower segment of the uterus and the cervix. This direct pressure causes stress in the lower uterine segment and probably the local production of prostaglandins

An amniotomy involves -

inserting a cervical hook (Amniohook) through the cervical os to deliberately rupture the membranes. This promotes pressure of the presenting part on the cervix and stimulates an increase in the activity of prostaglandins locally

Stripping of the membranes is accomplished by -

inserting a finger through the internal cervical os and moving it in a circular direction. This motion causes the membranes to detach. Manual separation of the amniotic membranes from the cervix is thought to induce cervical ripening and the onset of labor (Goldberg, 2012). However, there is no strong evidence at this time that membrane stripping significantly shortens the duration of pregnancy

Dystocia

is said to exist when the progress of labor deviates from normal; it is characterized by a slow and abnormal progression of labor. It occurs in approximately 8% to 11% of all labors and is the leading indicator for primary cesarean birth in the United States

An umbilical cord prolapse

is the protrusion of the umbilical cord alongside (occult) or ahead of the presenting part of the fetus The risk is increased further when the presenting part does not fill the lower uterine segment, as is the case with incomplete breech presentations (5% to 10%), premature infants, and multiparous women (Brailovschi, Sheiner, Wiznitzer, Shahaf, & Levy, 2012). With a 50% perinatal mortality rate, it is one of the most catastrophic events in the intrapartum period

An unripe cervix is -

long, closed, posterior, and firm. Cervical ripening usually begins prior to the onset of labor contractions and is necessary for cervical dilation and the passage of the fetus.

Multifetal pregnancy abnormalities

may include hydrocephalus, ascites, or a large mass on the neck or head.

Umbilical cord prolapse - changing the woman's position -

modified Sims, trendelenburg, or knee-chest position.

The products available include natural -

natural osmotic dilators (laminaria, a type of dried seaweed) and synthetic dilators containing magnesium sulfate (Lamicel, Dilapan).

Shoulder dystocia is defined as

obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. The incidence of shoulder dystocia is increasing due to increasing birth weight, with reports of it in up to 2% of vaginal births. It is one of the most anxiety-provoking emergencies encountered in labor. Failure of the shoulders to deliver spontaneously places both the woman and the fetus at risk for injury.

Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia. These variations can affect the contractions or fetal descent through the maternal pelvis. Common problems involving the fetus include

occiput posterior position, breech presentation, multifetal pregnancy, excessive size (macrosomia) as it relates to CPD, and structural anomalies

Another nonpharmacologic method suggested for labor induction is sexual intercourse along with breast stimulation. This promotes the release of

oxytocin, which stimulates uterine contractions. In addition, human semen is a biologic source of prostaglandins used for cervical ripening. According to a Cochrane review, sexual intercourse with breast stimulation would appear beneficial, but safety issues have not been fully evaluated, nor can this activity be standardized. It appears to shorten the latent phase of labor (Tharpe, Farley, & Jordan, 2013). Therefore, its use as a method for labor induction is not validated by research.

Placenta previa is

placental implantation in the lower uterine segment over or near the internal os of the cervix, typically during the second or third trimester of pregnancy. With uterine segment formation and cervical dilation, placental implantation over or near the cervical os, instead of along the uterine wall, inevitably results in spontaneous placental separation—and subsequent hemorrhage

There are multiple medical and obstetric reasons for inducing labor, the most common being

prolonged gestation. Other indications for inductions include PPROM, gestational hypertension, cardiac disease, renal disease, chorioamnionitis, dystocia, intrauterine fetal demise, isoimmunization, and diabetes

Fetal death can be due to numerous conditions, such as -

prolonged pregnancy, infection, hypertension, advanced maternal age, Rh disease, uterine rupture, diabetes, congenital anomalies, cord accident, abruption, blunt trauma, premature rupture of membranes, or hemorrhage— or it may go unexplained (Gilbert, 2011). Trauma in pregnancy remains one of the major contributors to maternal and fetal morbidity and mortality. Potential complications include maternal injury or death, shock, internal hemorrhage, intrauterine fetal demise, direct fetal injury, abruptio placentae, and uterine rupture.

The incidence of maternal mortality is less than 1%, but common morbidities include

septicemia, renal failure, hemorrhage and hypovolemic shock, invasive placenta (accrete, increta, and percreta), and postpartum anemia. The risk for perinatal mortality is less than 10%, but common neonatal morbidities include stillbirth, prematurity, malpresentation, IUGR, and fetal anemia

Cervical ripeness is an important variable when labor induction is being considered. A ripe cervix is

shortened, centered (anterior), softened, and partially dilated.

Mechanical methods are used to open the cervix and stimulate the progression of labor. All share a similar mechanism of action: application of local pressure stimulates the release of prostaglandins to ripen the cervix. Potential advantages of mechanical methods, compared with pharmacologic methods, may include

simplicity or preservation of the cervical tissue or structure, lower cost, and fewer side effects.

Maternal signs and symptoms of placenta previa include

sudden, painless bleeding (that may be heavy enough to be considered hemorrhaging), anemia, pallor, hypoxia, low blood pressure, tachycardia, soft and nontender uterus, and rapid, weak pulse. Bleeding may be episodic, with spontaneous initiation and cessation; in some cases, it is asymptomatic.

Cervical ripening is a process by which

the cervix softens via the breakdown of collagen fibrils. It is the first step in the process of cervical effacement and dilation so that, on average, the cervix is approximately 50% effaced and 2 cm dilated at the onset of labor, although wide differences do exist. There has been increasing awareness that if the cervix is unfavorable or unripe, a successful vaginal birth is unlikely.

Discontinue the oxytocin and notify the birth attendant if

uterine hyperstimulation or a nonreassuring FHR pattern occurs

Management of placenta previa

varies by type and gestational age, and frequent medical surveillance may be sufficient in marginal cases; prompt treatment with bed rest, close monitoring, and control/replacement of blood loss greatly reduces risk for maternal and fetal complications and death. Vaginal delivery is possible when bleeding is minimal, placenta previa is marginal, or labor is rapid. Pregnancy termination, early birth by cesarean section, or a hysterectomy may be necessary in order to control severe bleeding, especially for clients with complete placenta previa. The overall maternal prognosis is good if hemorrhage is controlled and sepsis or other complications are prevented. Fetal prognosis is directly related to the amount of blood loss. The U.S. perinatal mortality rate associated with placental previa is 2% to 3%, and the maternal mortality rate is 0.03%. Risk for placenta previa recurrence in subsequent pregnancies is 4% to 8%

If a dysfunctional labor occurs, contractions will

will slow or fail to advance in frequency, duration, or intensity; the cervix will fail to respond to uterine contractions by dilating and effacing; and the fetus will fail to descend.

Face and brow presentations are rare and are associated

with fetal abnormalities (anencephaly), pelvic contractures, high parity, placenta previa, hydramnios, low birth weight, or a large fetus

Breech presentation, which occurs in 3% to 4% of labors, is frequently associated

with multifetal pregnancies, grand multiparity (more than five births), advanced maternal age, placenta previa, hydramnios, preterm births, uterine malformations or fibroids, and fetal anomalies such as hydrocephaly (Fischer, 2011). In a persistent breech presentation, an increased frequency of prolapsed cord, placenta previa, low birth weight from preterm birth, fetal or uterine anomalies, and perinatal morbidity and mortality from a difficult birth may occur (Cunningham et al., 2010). Perinatal mortality is increased two- to fourfold with a breech presentation, regardless of the mode of delivery. Recent research has found that a planned surgical birth versus a vaginal birth does improve perinatal outcomes

In general, the grief accompanying the loss of a fetus proceeds in the following order:

•Accepting the reality of the loss •Getting over suffering from the loss •Adapting to the new environment without the deceased •Emotionally relocating the deceased and getting on with life