Chapter 8 Nursing Care of Women with Complications During Labor and Birth
After insertion of the prostaglandin gel, the woman remains on bed rest for ____ to _____ hours and is monitored for uterine contractions.
1 to 2
List and describe the three variations of uterine rupture:
1.Complete rupture: There is a hole through the uterine wall, from the uterine cavity to the abdominal cavity. 2.Incomplete rupture: The uterus tears into a nearby structure, such as a ligament, but not all the way into the abdominal cavity. 3.Dehiscence: An old uterine scar, usually from a previous cesarean birth, separates.
After ____ to ____ hours of cold applications, warmth in the form of heat packs or sitz baths increases blood circulation, enhancing comfort and healing.
12 to 24
If it appears that preterm birth is inevitable, the physician may give the woman steroid drugs (glucocorticoids) to increase fetal lung maturity if the gestation is between ____ to _____ weeks.
24 and 34
A large fetus (macrosomia) is generally considered to be one that weighs more than ________ at birth.
4000 g (8.8 lb)
The FDA recommends limiting the use of magnesium sulfate to fewer than _____ to ____ days, why? (eclampsia/mom)
5 to 7, because the fetus can develop low blood calcium and bone problems with prolonged use
Dysfunctional Labor/ Difficult labor:
Age -older Obesity Overdistended uterus Abnormal presentation Dehydration Lack of analgesic
The artificial rupture of membranes •Done to stimulate or enhance contractions
Amniotomy
Oxytocin:
Assess BP and cervix prior to giving ______
What is a side effect of β-Adrenergic drugs such as terbutaline (Brethine)?
Cardiac side effects such as increased pulse rate and blood pressure can occur
Dysfunctional Labor/ Difficult labor:
Cephalic disproportion Uterus overstimulated Fatigue Fear Multigravida Ineffective pushing
______ _____ is the physical softening of the cervix that leads to effacement and dilation.
Cervical ripening
What should be applied to the perineum for at least the first 12 hours to reduce pain, bruising, and edema after episiotomy or laceration?
Cold packs
______ is a term used to describe a difficult labor.
Dystocia
•Fourth degree:
Extends through the anal sphincter into the rectal mucosa
What are the three most common signs of fetal compromise?
Fetal heart rates outside the normal range of 110 to 160 beats/min, late decelerations, and loss of variability
_________is a protein produced by the fetal membranes that can leak into vaginal secretions if uterine activity, infection, or cervical effacement occurs.
Fibronectin
_______labor dysfunction is less common than _______ dysfunction.
Hypertonic labor dysfunction is less common than hypotonic dysfunction.
Gestational hypertension •Ruptured membranes without spontaneous onset of labor •Infection within the uterus •Medical problems in the woman that worsen during pregnancy •Fetal problems such as slowed growth, prolonged pregnancy, or incompatibility between fetal and maternal blood types •Placental insufficiency •Fetal death
INDICATIONS FOR LABOR INDUCTION
Perineal lacerations and often episiotomies are described by the amount of tissue involved: •First degree:
Involves the superficial vaginal mucosa or perineal skin
•Second degree:
Involves the vaginal mucosa, perineal skin, and deeper tissues of the perineum
When is hypertonic labor more likely to occur?(Increased muscle tone)
It is more likely to occur during latent labor, before 4 cm of cervical dilation
At what point in labor is hypotonic labor more likely to occur?
It occurs during the active phase, after 4 cm of cervical dilation
______ and _______ are mechanical dilators placed in the lower uterine segment that stimulate the release of prostaglandins from the fetal membranes and maternal decidua.
Laminaria and Lamicel
List three positions that can improve the pressure exerted on the cord when it is prolapsed.
Maternal positions such as the knee-chest, a side-lying position with her hips elevated on pillows, or Trendelenburg.
CAUSES OF PRETERM DELIVERY
Multiple births Illness of the mother (malnutrition, heart disease, DM, infectious conditions) Hazards of pregnancy (gestational HTN, placental abnormalities, placenta previa, and premature separation of the placenta) In many instances the cause is unknown UTI
Oxytocin induction and augmentation:
Must have a Bishop score of >6 or will cause a uterine rupture. Pitocin is the most often used for induction and augmentation. Diluted in IV solution. Piggybacked in non-medicated solution From high to low amount. Augmentation requires low amount Continuous monitor of maternal response and fetal HR. Internal monitoring preferred when used with pitocin.
CONTRAINDICATIONS TO LABOR INDUCTION (7)
Placenta previa •Umbilical cord prolapse •Abnormal fetal presentation •High station of the fetus •Active herpes infection in the birth canal •Abnormal size or structure of the mother's pelvis •Previous classic cesarean incision
________ is spontaneous rupture of the membranes at term (38 or more weeks of gestation) more than 1 hour before labor contractions begin.
Premature rupture of membranes (PROM)
Oxytocin:
Produced by posterior of pituitary gland Stimulates uterine contraction Is inhibited by progesterone during pregnancy After birth, helps keeps uterus contracted Stimulates milk ejection reflex during breast feeding
What are two typical characteristics of the fetus with postmaturity?
The fetus may lose weight, and the skin may begin to peel
An ________ is the injection of warmed sterile saline or lactated Ringer's solution into the uterus via an intrauterine pressure catheter during labor after the membranes have ruptured.
amnioinfusion
How long does a late-term pregnancy last?
between 41 weeks and 41 weeks and 6 days.
Oxytoxin used to induce labor without a "ripe cervix" can result in the need for a ______ ______.
cesarean section
Levels of maternal __________ increase significantly in the weeks before preterm labor.
corticotropin-releasing hormone (CRH)
Describe tocolytics.
drugs that reduce uterine contractions
When ocytocin is being administered, how often is the woman's blood pressure, pulse rate, and respirations measured?
every 30 to 60 minutes
When ocytocin is being administered, how often should fetal heart rate be monitored during active labor? Transitional stage?
fetal heart rate every 15 minutes during active labor and every 5 minutes during the transitional phase.
The ________ pelvis is the most favorable for vaginal birth.
gynecoid
The mother is more likely to have a _________of her vaginal wall if the fetus remained in the occiput posterior position for a long time.
hematoma
Amniotic fluid embolism is characterized by abrupt onset of what three things?
hypotension, respiratory distress, and coagulation abnormalities triggered by the thromboplastin contained in the amniotic fluid.
What are the three contraindications to cesarean birth?
if the fetus is dead or too premature to survive or if the mother has abnormal blood clotting.
Abruptio placentae is more likely to occur if.....
if the uterus is overdistended with amniotic fluid (hydramnios) when the membranes rupture.
What are five conditions in which tocolytics should not be used?
in women with preeclampsia, placenta previa, abruptio placentae, chorioamnionitis, or fetal demise.
Cloudy, yellow, or malodorous amniotic fluid suggests _________.
infection
Birth injury from rapid passage through the birth canal may become evident in the infant after birth. These injuries can include ____ (2).
intracranial hemorrhage or nerve damage.
Betamethasone may be administered for this purpose in two ____________ injections ______ hours apart.
intramuscular:24
The presence of increased fibronectin in vaginal secretions between 22 and 24 weeks of gestation is predictive of _____ ____.
preterm labor.
_________, is rupture of the membranes before term (before 37 weeks of gestation) with or without uterine contractions.
preterm premature rupture of membranes (PPROM)
Three complications associated with amniotomy may also occur if a woman's membranes rupture spontaneously (spontaneous rupture of membranes [SROM]):
prolapse of the umbilical cord, infection, and abruptio placentae.
Oligohydramnios in a gestation less than 24 weeks can lead to fetal ____ and _____ defects.
pulmonary and skeletal
When magnesium sulfate is used, the nurse should monitor the patient for what six things? (seizures in women with eclampsia)
respiratory rate and lung sounds and signs of fluid overload, urine output, deep tendon reflexes, and bowel sounds, because the intestinal muscles also relax in response to the drug.
β-Adrenergic drugs such as _______ are administered subcutaneously to stop uterine contractions.
terbutaline (Brethine)
What does green amniotic fluid mean?
that the fetus passed the first stool (meconium) into the fluid before birth.
What does stimulating the nipples cause?
the woman's posterior pituitary gland to secrete oxytocin naturally.
Before labor is induced, it is important that fetal maturity be confirmed by __________. (4)
ultrasound, amniotic fluid analysis, presence of increased fetal fibronectin at the cervix and the Bishop score above 6.
If the woman's tissues do not yield easily to the powerful contractions, she may experience what three things?
uterine rupture, cervical lacerations, or hematoma.
What does severe and poorly relieved pelvic or rectal pain after forceps and vacuum extraction births indicate?
vaginal hematoma, and the physician is notified
The use of prostaglandins to ripen the cervix is contraindicated in women with a history of what? Why?
with a history of uterine myomectomy surgery or previous cesarean section because of the risk of uterine rupture.
Risks caused by cesarean to the newborn may include the following:
•Inadvertent preterm birth •Respiratory problems because of delayed absorption of lung fluid •Injury, such as laceration or bruising
In addition to stopping the oxytocin infusion, the registered nurse chooses one or more of the following measures to correct adverse maternal or fetal reactions: (3)
•Increasing the nonmedicated intravenous solution •Changing the woman's position, avoiding the supine position •Giving oxygen by facemask at 8 to 10 L/min
Prolonged labor can result in several problems, including the following:
•Maternal or newborn infection, especially if the membranes have been ruptured for a long time (usually about 24 hours) •Maternal exhaustion •Postpartum hemorrhage (see Chapter 10) •Greater anxiety and fear in an ensuing pregnancy
Indications for an amnioinfusion include the following: (4)
•Oligohydramnios (lower-than-normal amount of amniotic fluid) •Umbilical cord compression resulting from lack of amniotic fluid •Goal of reducing recurrent variable decelerations in the fetal heart rate •Goal of diluting meconium-stained amniotic fluid to prevent meconium aspiration syndrome.
What are six signs and symptoms of uterine rupture?
•Shock •Abdominal pain •Pain in the chest •Cessation of contractions •Abnormal or absent fetal heart tones •Palpation of the fetus outside the uterus
Prolapse of the umbilical cord is more likely to occur in what four situations?
•The fetus is high in the pelvis when the membranes rupture (presenting part is not engaged). •The fetus is very small, as in prematurity. •There are abnormal presentations, such as footling breech or transverse lie. •Hydramnios (excess amniotic fluid) is present.
Recovery-room assessments after cesarean birth include the following: (7)
•Vital signs to identify hemorrhage or shock; a pulse oximeter is used to better identify depressed respiratory function •IV site and rate of solution flow •Fundus for firmness, height, and midline position •Dressing for drainage •Lochia for quantity, color, and presence of clots •Urine output from the indwelling catheter •Return of sensation to the lower body