Flashcards in Exam 3 Deck (138):
Manipulation of fetus from abnormal position (breach), to vertex position.
Nurses role for External Version
Monitor: maternal vitals, FHR, unusual pain or bleeding, and fetus after procedure.
Induction of Labor ...?
Chemical (IV Oxytocin) or mechanical (Amniotomy) initiation of uterine contractions.
The determination if cervix is favorable for an induction of labor with Pitocin.
The Bishop score needed to perform an induction of a nullipara
9 or more
The Bishop score needed to perform an induction of a miltipara
5 or more
The method used in an primipara with a Bishop score greater than 9
The method used in a primipara with a Bishop score less than 9
Cervical Ripeners first
The method used in a multipara with a Bishop score less than 5
Cervical Ripeners first
The method used in a multipara with a Bishop score of 5 or more
The two agents used for cervical ripening
Prostaglandin E1: Misoprostol (Cytotec)
Prostaglandin E2: Cervidil (med put behind uterus, looks like a tampon)
Medications used to make cervix softer and thinner, stimulates uterine contractions, and used when Bishop score is <5 for multipara and <9 for primipara.
Adverse effect of cervical ripening
Hyperstimulation of uterus, may go into labor without need for pitocin
How do Laminaria work?
Laminaria is only used when its the best chance at dilation without the use of chemicals due to allergies. Function like tampons- as absorbs fluid, expands and causes cervical dilation. Left in place for 6-12 hours. Can cause an increase in discomfort for woman.
What must happen for an amniotomy to be performed?
fetus must be at 0 station
What is important to monitor after an amniotomy?
What can increase the risk of prolapsed cord & infection?
If the cord prolapsed - what do you do?
Place woman in knee-chest position or in bed trendelenberg.
SVE- if find prolapsed cord, do not remove your fingers- hold presenting pat off cord until baby is delivered by cesarian section.
Signs of meconium-stained fluid
What does bloody amniotic fluid possibly indicate?
placental abruption or fetal trauma
Goal of oxytocin
To achieve a contraction pattern that stimulates the active phase of labor- moderate to severe contractions every 2-3 minutes.
hazard of oxytocin to fetus
maternal hazards of oxytocin
water intoxication- only with large amounts
titanic contractions: rupture of uterus, placental separation, lacerations of cervix, and postpartum hemorrhage.
What to do with uterine hyperstimulation of uterus with oxytocin
1. turn off oxytocin
2. administer O2 8-10L/min facial mask
3. open mainline- main IV
4. turn woman to left side
5. notify PCP
6. prepare to administer medication to stop contractions
7. monitor FHR closely
Conditions for use of forceps
cervix fully dilated
presenting part engaged
rupture of membranes
Maternal assessment after forcep use
vaginal and cervical lacerations
Newborn assessment after forcep use
brushing or abrasions
Implications of vacuum-assisted birth
assist with delivery, prevent worsening cardiac problems in mom, fetal distress, absence of cephalopelvic disproportion (CPD)(fetal head will not engage with he pelvis)
Newborn implications with vacuum-assisted birth
monitor for cephalohematoma
caput succedaneum is normal and will resolve
Fetal indications of C-Section
Malpresentation (breach, transverse)
Cephalopelvic Disproportion (CPD)
umbilical cord prolapse
Maternal indications of C-Section
active genital herpes
positive HIV status
The incision made during emergency C-section delivery that cuts through the fundus of uterus. Higher incidence of blood loss, infection, and uterine rupture in future pregnancies. After this surgical technique, vaginal birth is contraindicated.
Surgical incision made during C-section that is less likely to rupture uterus (b/c not cutting through fundus), associated with decreased blood loss and fewer postop infections
fetal effects of general anesthesia
baby will become too sedated to breathe
Low birth weight is
2500 grams or less
Very low birth weight
1500 grams or less
extremely low birth weight
1000 grams or less
Biophysical risks associated with low birth weight
previous preterm birth or labor
2nd trimester abortion
grand multiparity- short intervals between pregnancies
uterus and cervical anomalies
S/S of preterm birth
UTERINE: contractions every 10 minutes or more frequently and lasting 1 hour or more
may be painless or associated with infection
dilated 2cm or grater than 80% effaced
DISCOMFORT: lower abdominal or menstrual like cramping
lower back pain
ROM , bloody, watery, odor
Glycoproteins found in cervical canal in late pregnancy
Fetal Fibronectin- biochemical marker of preterm birth
when is fetal fibronectin performed?
22-35 weeks and only done on those with symptoms of preterm labor, intact membranes, cervix not dilated past 3cm, and only slight vaginal bleeding.
Results of a fetal fibronectin test?
Negative- no labor for 2 weeks
Positive- less reliable and unable to pinpoint when labor will occur. Is a better predictor of who will not deliver than who will.
Uses of Tocolytic durgs
suppress uterine contractions
potential serious effects
Medical management of preterm birth
Indication of use for Betamethasone
Women 24-34 weeks gestation with signs of preterm labor at risk to deliver preterm.
What does Betamethasone do?
Stimulates production of more mature surfactant in the fetal lungs to prevent respiratory distress syndrome in preterm infants.
Route and dose of Betamethasone
12 mg Im every 24 hr x 2 doses. Only used once during a pregnancy.
Medications most commonly used to suppress uterine activity
Action of mag sulfate
CNS depressant and relaxes smooth muscles (Uterus)
Doses of Mag Sulfate
Loading dose- 4-6 grams/20 minutes
Maintenance dose- 1-4 grams/hr
Adverse effects of Mag Sulfate
Therapeutic level of Mag Sulfate
Toxic levels of mag sulfate are manifested by
loss of deep tendon reflexes
respiratory rate of 10-12/min
altered level of consciousness
complaints of being too warm
Mag sulfate antidote
Fetal implications of mag sulfate
decreased variability- CNS sedation, upon birth not wanting to breathe right away
neonatal implications of mag sulfate
Med previously used to treat asthma, is now used to quiet uterine muscles.
Adverse Effects of (Terbutaline) Brethine
shortness of breath
Reasons to help Terbutaline (Brethine)
Maternal HR above 120
BP less than 90/60
signs of pulmonary edema
FHR greater than 180 bpm
Action of Nifedipine
relax smooth muscle by blocking calcium entry
Usually used after stabilization with mag sulfate
Dosage/route of Nifedipine
30mg oral loading dose, 10-20mg every 4-6 hours
Nifedipine cannot be used with which drug because hypotension can result
Action of Indomethacin (indocin)
relaxes uterine smooth muscle by inhibiting prostaglandins
This drug is good for preterm labor caused by polyhydramnios - causes oligohydramnois. Only used when fetus is less than 32 weeks gestation, may cause premature closure of the ductus arteriosus.
maternal contraindications to tocolytics
hypertension (beta agonists)
significant vaginal bleeding
fetal Contraindications to tocolytics
Gestational age more than 34 weeks
lethal fetal anomaly
evidence of acute or chronic fetal compromise
rupture of amniotic sac beginning at least 1 hour before onset of labor and any gestational age
Premature Rupture of Membranes (PROM)
major complication of PROM
rupture of membranes before 38 weeks
Prolonged rupture of membranes
Rupture greater than 24 hours before delivery
newborn risk of PROM
fetal or neonatal sepsis
hypoxia or asphyxia because of umbilical cord compression
fetal deformities if occurs before 26 weeks
Management of PROM
fetal and uterine assessments
frequent biophysical profiles
vigilant assessment for signs of infections - prophylactic antibiotics
assess fetal lung maturity
NOTHING IN VAGINA
if term- induction of labor
difficult labor that is prolonged and more painful than ordinary
dystocia of labor
incompetent cervix is associated with???
previous cervical trauma and DES exposure in utero
Medical management of incompetent cervix
Prophylactic cerclage between 12-16 weeks
Incompetent cervix can lead to what?
multiple second-trimester miscarriages without contractions
Nursing actions of a woman with an incompetent cervix
monitor for uterine activity per palpation
monitor for vaginal bleeding and leaking of fluid/rupture of membranes
no fetal monitoring because fetus not viable.
monitor for infection and uterine tenderness
What can cause dystocia of labor?
catecholamines, released during times of stress
pelvic or soft tissue dystocia
FETAL: anomalies, CPD, malpresentation, multifetal pregnancy
Assessment and interventions of Dystocia of labor
excessive pain without progress
abnormal contraction patterns
maternal or fetal tachycardia
Provide rest and comfort - sedation and pain relief
Fetal head is delivered, but anterior shoulder is stuck under pubic arch.
Signs of shoulder dystocia
formation of caput increasing in size
what is McRoberts maneuver
Womens legs flexed part with knees on abdomen
Interventions of shoulder dystocia
Labor lasting less than three hours
Maternal complications of precipitous labor
Amniotic fluid embolism
Fetal complications of precipitous labor
Hypoxia caused by contractions being too close together and don't allow oxygen to fetus
risk of vaginal birth after c-section
an escape of amniotic fluid into maternal circulation, deposits in pulmonary arterioles, is usually fatal to mother.
Amniotic Fluid Embolism
Occurs before 20 weeks gestation, most occur before 12
less than 500 grams
Before week 12- Heavy period
After week 12- severe pain similar to labor
spotting, cervical os closed, mild cramping
Moderate to heavy bleeding, mild to severe cramping, ROM, cervical dilation.
expulsion of fetus, retention of placenta (stuck)
all fetal tissue expelled and cervix is closed
fetus who has died, all products of conception remain in utero. No cramping. Usually discovered in OB office.
Management of Threatened Miscarriage
monitor levels of HCG and progesterone
Inevitable and Incomplete miscarriage management
if products retained- suction curettage
management of a missed miscarriage
spontaneous resolution- misoprostol (Cytotec) orally
surgical intervention- scar tissue with manual dilation and curettage (D&C) is a big concern.
What is given after evacuation of uterus
Pitocin- to contract
if pt is hemorrhaging- Hemobate (Prostaglandin)
Ibuprofen for cramping
if Rh -, give Rhogam for future
Recurrent premature dilation of cervix- History of two pregnancy losses
Dull-colicky pain- sharp pain as pregnancy grows
if ruptured, shoulder pain common
Manifestations of Ectopic pregnancy
Medical management of tubal pregnancy
Methotrexate- attracted to the breakdown of the pregnancy in tube then flushes away
Surgical management of tubal pregnancy is dependent on
woman desire for fertility, location, and extent of tissue involvement
Fertilization of empty egg (no nucleus)
chorionic villli develop into grape like clusters
can lead to choriocarncinoma
Hydatiform Mole Pregnancy- Molar Pregnancy- Gestational Trophoblastic Disease
Manifestations of molar pregnancy
dark brown or bright red bleeding
larger than expected uterus
excessive nausea and vomiting
What will be seen on a Transvaginal ultrasound of molar pregnancy
snow storm pattern
management of a molar pregnancy
support pt and family as if a baby actually happened
follow up care of molar pregnancy
frequent physical and pelvic examinations- weekly b-hCG , until levels are normal for 3 weeks.
Monthly measurements follow for 6 months
Follow up for one year
Postpone future pregnancies for one year
Continued bleeding after evacuation of mole is usually the most suggestive symptom of what?
Gestational trophoblastic neoplasia
Placenta implanted in lower uterine segment near or over internal cervical os
The three types of placenta previa
Complete- totally covers internal cervical os
Marginal- edge of placenta close to cervical os
Low-Lying- close to cervical os
Clinical manifestations of placenta previa
Painless bright red vaginal bleeding during second or third trimester
Bright red bleeding
normal uterine tone
FHR usually normal unless major detachment
Maternal outcomes of placenta previa
major implication for hemorrhage
can loose up to 40% of blood volume without displaying signs of shock
Management of placenta previa
any excessive, persistent bleeding- C-section (if 36 weeks)
Detachment of part or all of placenta from implantation site after 20 weeks gestation
Risk factors of placenta abruption
cocaine use- vasoconstrictor
blunt abdominal trauma- car accident, battering
Manifestations of placenta abruption
abdominal pain, vaginal bleeding, uterine tenderness and contractions. Depends on degree of separation
Maternal outcomes of placenta abruption dependent on
extent of placental detachment, blood loss, degree of coagulopathy present, time between placental detachment and birth
Fetal outcomes of placental abruption
fetal death if more than 50% of the placenta is involved
Active management of placental abruption
immediate birth for term fetus, or if bleeding is moderate to severe. vaginal birth if possible- C-section if fetal distress.
frequent maternal vitals
Rare Placental anomaly associated with placenta previa and multiple gestation
Velamentous insertion (Vasa Previs) (Cord Insertion)
Cord Insertion risks
ROM or traction on the cord may tear on or more of the fetal vessels
Fetus may rapidly bleed to death
Pregnancy-specific syndrome in which hypertension develops after 20 weeks of gestation in a previously normotensive woman
Key characteristics of preeclampsia (PRE)
Rise in BP
Uncontrolled preeclampsia, onset of seizure activity or coma in a woman with preeclampsia.
Hypertension present BEFORE pregnancy or diagnosed before week 20.
Symptoms of Preeclampsia
Brain- ischemia -> headaches -> seizures
Kidneys- decreased output, increases BUN + Creatinine
Retina- blurred vision
Liver- increased ALT + AST, epigastric pain due to shifting of liver
Placenta- IUGR, late decels
Can you identify preeclampsia?
No reliable test or screening tool has been developed
Home care of mild preeclampsia and hypertension
decreased sodium diet
Dipstick urine to assess proteinuria
Call with less than 4 fetal movements/hour
NST/BPP weekly or biweekly
Antepartum care of severe gestational hypertension and preeclampsia
bet rest with side rails up
Mag sulfate therapy
antihypertensive medications- Hydralazine (Apresoline)
Report any changes in symptoms with severe hypertension and preeclampisa
BP above 160 systolic or above 110 diastolic
respirations above 12/min
output less than 25-30cc/hr
Med to give to prevent seizures in preeclamptic patients
Mag sulfate- CNS depressant
Used to prevent stroke if BP is above 160/110
Delivery with preeclampsia and hypertension
at least 34 weeks, less than 34 weeks...betamethasone
immediate delivery: fetal distress, eclampsia, placental abruption, HELLP syndrome
Intrapartum interventions for Severe Preeclampsia
fluids limited to 125ml/hr
emergency meds at bedside (hydralazine + calcium gluconate)
Induction of labor
Postpartum with severe preeclampsia
Mag sulfate continues for 12-24 hours, symptoms usually resolve after 48 hours
woman goes home on antihypertensive meds (nifedipine, labetalol) , HTN usually persists
Immediate care of eclampsia
do not leave pt, could have seizure
monitor for persistent headache and blurred vision
What med will break a seizure?