High Risk Labor and Birth- 10

Question 1

Dystocia

Answer 1

difficult labor that is characterized by abnormally slow labor progress

Question 2

Hypertonic uterine dysfunction

Answer 2

uncoordinated uterine activity

Contractions are frequent and painful but ineffective in promoting dilation and effacement.

Question 3

Risk factors for dystocia

Answer 3

● Congenital uterine abnormalities such as bicornate uterus.

● Malpresentation of the fetus such as occiput posterior, or face presentation.

● Cephalopelvic disproportion.

● Tachysystole of the uterus with oxytocin.

● Maternal fatigue and dehydration.

● Administration of analgesia or anesthesia early in labor.

● Extreme maternal fear or exhaustion, which can result in catecholamine release interfering with uterine contractility.

Question 4

Hypertonic uterine dysfunction risk factor

Answer 4

Nulliparous women

Question 5

Hypertonic uterine dysfunction s/s

Answer 5

●Painful, frequent UCs with inadequate uterine relaxation between UCs with little cervical changes

● May be Category II (indeterminate) or Category III (abnormal) fetal heart rate (FHR) related to prolonged labor and inadequate uterine relaxation

Question 6

Hypotonic uterine dysfunction

Answer 6

when the pressure of the UC is insufficient to promote cervical dilation and effacement.

Question 7

Hypotonic uterine dysfunction risk factors

Answer 7

● Multiparous women

● Extreme fear

Question 8

Hypotonic uterine dysfunction s/s

Answer 8

● Decreased frequency, strength, and duration of UCs

● Little or no cervical change

● Increased fear and anxiety levels

Question 9

First-Stage Arrest: Spontaneous labor

Answer 9

greater than 6 cm dilation with membrane rupture and more than 4 hours of adequate contractions or more than 6 hours if contractions are inadequate with no cervical change

Question 10

Induced labor:

Answer 10

greater than 6 cm dilation with membrane rupture or greater than 5 cm without membrane rupture and more than 4 hours of adequate contractions, or more than 6 hours if contractions are inadequate with no cervical change

Question 11

Second-Stage Arrest

Answer 11

No progress for 4 hours or more in nulliparous women with an epidural

3 hours or more in nulliparous women without an epidural

3 hours or more in multiparous women with an epidural

2 hours or more in multiparous women without an epidural

Question 12

Second-Stage Arrest s/s

Answer 12

● Inadequate or ineffective pushing with little or no descent of the fetal head with expulsive pushing efforts

● Potential for Category II (indeterminate) or Category III (abnormal) FHR

Question 13

Second-Stage Arrest risk

Answer 13

● Maternal exhaustion

● Epidural anesthesia because woman may not feel the urge to push

Question 14

Precipitous labor

Answer 14

labor lasting fewer than 3 hours from onset of labor to birth.

Question 15

Precipitous labor risk factors

Answer 15

● Grand multiparity

● History of precipitous labor

Question 16

Precipitous labor s/s

Answer 16

● Hypertonic UCs (tetanic UCs) occurring every 2 minutes or more frequently, lasting greater than 60 seconds and strong
● Rapid cervical dilation such that labor is less than 3 hours.
● Potential for Category II (indeterminate) or Category III (abnormal) FHR and nursing actions are based on FHR pattern

Question 17

Fetal dystocia

Answer 17

Baby is not in the right position for birth

caused by excessive fetal size, malpresentation, multifetal pregnancy, or fetal anomalies.

Question 18

Fetal dystocia s/s

Answer 18

● FHR may be heard above the umbilicus versus in the lower uterine segment; this is a sign that the fetus may be in position other than vertex.

● The SVE reveals buttocks or face when malpresentation is the cause of dystocia.

● The presenting part is not engaged in the maternal pelvis.

● There is no fetal descent through the pelvis.

Question 19

Fetal dystocia risk factor

Answer 19

● Contraction or narrowing of the pelvic inlet, the midpelvis, or the pelvic outlet

● Abnormal fetal presentation or position such as asynclitism, face, brow presentation, or breech or transverse lie

● Fetal anomalies, such as hydrocephalus, and/or any other fetal anomaly that interferes with fetal descent through the birth canal

Question 20

Pelvic dystocia

Answer 20

the contraction of one or more of the three planes of the pelvis.

Question 21

Pelvic dystocia risk factors

Answer 21

● Small pelvis

● Abnormal pelvic shape

Question 22

Induction of labor

Answer 22

deliberate stimulation of UCs before the onset of spontaneous labor to facilitate a vaginal delivery

If done for nonmusical reasons it should be done after 39 weeks

Question 23

Before elective induction of labor fetal maturity must be confirmed to be 39 weeks or greater by:

Answer 23

1. Ultrasound before 20 weeks’ gestation confirms gestational age of 39 weeks or greater.
2. Fetal heart tones have been documented as present by Doppler for 30 weeks.
3. It has been 36 weeks since a positive serum or urine pregnancy test was confirmed.

Question 24

Medical reasons for induction of labor

Answer 24

● Abruptio placentae

● Chorioamnionitis (intraamniotic infection)

● Fetal demise

● Gestational hypertension

● Preeclampsia, eclampsia

● Premature rupture of membranes

● Post-term pregnancy

● Maternal medical conditions
● Fetal compromise

Question 25

Mistimed cervical ripening and induction can lead to what

Answer 25

unplanned iatrogenic preterm birth, and recent evidence documents increased neonatal morbidity in babies born prior to 39 weeks’ gestation but after 37 weeks’ gestation

Question 26

Oxytocin Induction

Answer 26

A pharmacological method for labor induction

Question 27

Nurses role in administering oxytocin in labor- titration

Answer 27

decreasing the dosage rate or discontinuing the medication when contractions are too frequent, discontinuing the medication when fetal status is indeterminate or abnormal, and increasing the dosage rate when uterine activity and labor progress are inadequate. Once active labor is established, oxytocin should be discontinued

Question 28

Oxytocin high alert medication- requirements

Answer 28

1. Requirement that women having elective labor induction be at least 39 completed weeks’ gestation 2. Standard order sets and protocols that reflect a standardized clinical approach to labor induction and augmentation based on current pharmacological and physiological evidence 3. Standard concentration of oxytocin prepared by the pharmacy 4. Standard definition of uterine tachysystole that does not include a Category III or II (abnormal or indeterminate) FHR pattern (a contraction frequency of more than five in 10 minutes, a series of single contractions lasting 2 minutes or more, contractions of normal duration occurring within 1 minute of each other) 5. Standard treatment of oxytocin-induced uterine tachysystole guided by fetal status

Question 29

Tachysystole

Answer 29

excessive uterine activity and can be either spontaneous or induced more than five contractions in 10 minutes, averaged over 30 minutes

Question 30

Nursing actions for tachysystole with Category I (normal) FHR pattern

Answer 30

* Maternal repositioning (left or right lateral) * IV fluid bolus of at least 500 mL lactated Ringer’s (unless contraindicated) * Oxygen 10 L/min via nonrebreather mask * If uterine activity has not returned to normal after 10 to 15 minutes, decrease oxytocin rate by at least half; if uterine activity has not returned to normal after 10 to 15 more minutes, discontinue oxytocin until uterine activity is normal.

Question 31

Nursing actions for tachysystole with a Category II (indeterminate) or Category III (abnormal) FHR pattern

Answer 31

* Discontinuing oxytocin and notifying the provider. * Maternal repositioning (left or right lateral). * Administering IV fluid bolus of at least 500 mL lactated Ringer’s (unless contraindicated). * Giving O2 at 10 L/min by nonrebreather mask. * Notifying provider of actions taken and maternal-fetal response. * With category III FHR pattern request an immediate bedside evaluation. * Considering terbutaline if no response to above measures.

Question 32

Cervical ripening

Answer 32

process of physical softening, thinning, and dilating of the cervix in preparation for labor and birth begins prior to the onset of labor contractions and is necessary for cervical dilation

Question 33

Bishop score

Answer 33

greater than 8 considered to indicate a favorable cervix 6 or less has been used to denote an unfavorable cervix

Question 34

Mechanical cervical ripening

Answer 34

devices that are inserted through the vagina and into the cervix to promote cervical dilation pharmacological prostaglandins have partially replaced mechanical methods

Question 35

Hygroscopic dilators

Answer 35

Several dilators are inserted into the cervix—as many as will fit—and they expand over 12 to 24 hours as they absorb water.

Question 36

Balloon catheters

Answer 36

30-mL to 50-mL Foley catheter filled with saline is effective in inducing cervical ripening and dilation.

Question 37

Risks of inductions- oxytocin

Answer 37

●Tachysystole ● Failed induction of labor ●tachysystole and subsequent FHR decelerations are common side effects ● Water intoxication can occur with high concentrations of oxytocin with large quantities of hypotonic solutions

Question 38

Risks Associated With Mechanical Cervical Ripening

Answer 38

● Higher infection rate ● Premature rupture of membranes (PROM)

Question 39

When we do mechanical cervical ripening

Answer 39

● When the woman has little or no cervical effacement ● When pharmacological methods are contraindicated, such as women with prior uterine incision

Question 40

Risks Associated With Pharmacological Methods of Cervical Ripening

Answer 40

● Tachysystole of the uterus

Question 41

Pharmacological methods of cervical ripening

Answer 41

variety of hormonal preparations placed in or near the cervix, produce cervical ripening by causing softening and thinning of the cervix

Question 42

Sweeping or stripping the membranes

Answer 42

digital separation of the chorionic membrane from the wall of the cervix and lower uterine segment during a vaginal exam done by a primary care provider to stimulate labor.

Question 43

Risks Associated With Membrane Sweeping

Answer 43

● Infection ● Bleeding from undiagnosed placental problem ● Unplanned ROM

Question 44

Amniotomy

Answer 44

artificial rupture of membranes (AROM) to induce or augment labor with an amnihook during a SVE

Question 45

Risks Associated With Amniotomy

Answer 45

● Severe variable decelerations ● Bleeding from undiagnosed vasa previa or other placental abnormality ● Umbilical cord prolapse when presenting part is not engaged ● Intraamniotic infection increases with duration of the rupture.

Question 46

External cephalic version (ECV)

Answer 46

the fetus is rotated from the breech to the cephalic presentation by manipulation through the mother’s abdomen

Question 47

Risks Associated With ECV

Answer 47

● Severe variable decelerations ● Umbilical cord compression

Question 48

Augmentation of labor

Answer 48

stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus usually with oxytocin

Question 49

Risks Associated With Augmentation

Answer 49

● Tachysystole leading to a Category II or Category III FHR pattern is a primary complication of oxytocin in labor

Question 50

Complementary Therapies to Stimulate Labor

Answer 50

``` Herbal preparations: ● Black cohosh ● Blue cohosh ● Evening primrose oil ● Raspberry leaves may be taken orally to promote prostaglandin or oxytocin production. ``` Sexual intercourse: ● Semen contains prostaglandin to open the cervix, and orgasm may be associated with prostaglandin and oxytocin release.

Question 51

Operative vaginal delivery

Answer 51

vaginal birth that is assisted by vacuum extraction or forceps

Question 52

Vacuum-assisted delivery

Answer 52

birth involving the use of a vacuum cup on the fetal head to assist with delivery of the head

Question 53

Vacuum-assisted delivery why

Answer 53

● Suspicion of immediate or potential fetal compromise ● Need to shorten the second stage for maternal benefit ● Prolonged second stage

Question 54

Vacuum-assisted delivery risk mom

Answer 54

● Vaginal and cervical lacerations ● Extension of episiotomy ● Hemorrhage related to uterine atony, uterine rupture ● Bladder trauma ● Perineal wound infection

Question 55

Vacuum-assisted delivery risk baby

Answer 55

● Intracranial hemorrhage and retinal hemorrhage ● Cephalohematoma (15%) and therefore increased risk of jaundice ● Scalp lacerations or bruising (10%)

Question 56

Cephalohematoma

Answer 56

collection of blood between a baby’s scalp and the skull.

Question 57

Forceps-assisted birth

Answer 57

an instrument is used to assist with delivery of the fetal head, typically done to improve the health of the woman or the fetus.

Question 58

Forceps-assisted birth why

Answer 58

● The fetal head engaged and the cervix is completely dilated. ● There is suspicion of immediate or potential fetal compromise. ● To shorten the second stage for maternal benefit ● Prolonged second stage ● High level of regional anesthesia that inhibits pushing

Question 59

Forceps-assisted birth risk mom

Answer 59

● Vaginal and cervical lacerations ● Extension of episiotomy ● Hemorrhage related to uterine atony, uterine rupture ● Perineal hematoma ● Bladder trauma ● Perineal wound infection

Question 60

Forceps-assisted birth risk baby

Answer 60

● Cephalohematoma ● Nerve injuries, including craniofacial and brachial plexus injuries ● Skin lacerations or bruising ● Skull fractures ● Intracranial hemorrhage

Question 61

Vaginal Birth After a Cesarean (VBAC) Benefits

Answer 61

shorter recovery time and overall lower morbidity and mortality, including less blood loss, fewer infections, and fewer thromboembolic problems

Question 62

TOLAC

Answer 62

planned attempt to labor by a woman who has previously undergone a cesarean delivery

Question 63

VBAC risks

Answer 63

● Risk of rupture of uterus ● Risk of failed TOLAC ●risk of uterine rupture ● low risk of fetal death

Question 64

Post-term pregnancy

Answer 64

one that has reached between 41 0/7 weeks and 41 6/7 weeks of gestation

Question 65

Post-term birth risk mom

Answer 65

difficulties during labor, an increase in injury to the perineum, increased rate of cesarean birth, infection, postpartum hemorrhage

Question 66

Post-term birth risk baby

Answer 66

● Stillbirth or neonatal death ● Macrosomia: Post-term fetuses have a greater chance of developing complications related to larger body size (macrosomia) ● Fetal dysmaturity: Also called post-maturity syndrome, this refers to a fetus whose growth in the uterus after the due date has been restricted ● Oligohydramnios-single deep vertical pocket of amniotic fluid of 2 cm or less ● Fetal macrosomia ● Meconium-stained fluid ● Decreased placental reserve

Question 67

Meconium-Stained Fluid and Birth

Answer 67

Meconium is the earliest stool of a mammalian infant, compression can cause release of meconium and be dangerous

Question 68

Meconium-Stained Fluid and Birth risk

Answer 68

Aspiration of meconium results in respiratory distress that in severe cases can be life-threatening

Question 69

Risks Associated With Multiple-Gestation Labor and Delivery

Answer 69

● Preterm labor ● Labor dystocia ● Antepartum hemorrhage ● Stillbirth

Question 70

Stillbirth, or intrauterine fetal demise (IUFD),

Answer 70

fetal death after 20 weeks’ gestation

Question 71

Stillbirth, or intrauterine fetal demise (IUFD) risk factors

Answer 71

``` ● 1/2 are unknown ●younger than 15 older than 45 ●lower socioeconomic mothers ●maternal medical issues ●drug and alcohol ●post term pregnancy ●extreme prematurity ●infections ```

Question 72

Intraamniotic Infection/Chorioamnionitis

Answer 72

infection with resultant inflammation of any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua

Question 73

Intraamniotic Infection risk factors

Answer 73

● Migration of cervicovaginal flora through the cervical canal ● Prolonged rupture of membranes. ● Obstetric risk factors for intraamniotic infection at term have been delineated, including low parity, multiple digital examinations, use of internal uterine and fetal monitors, meconium-stained amniotic fluid, and the presence of certain genital tract pathogens

Question 74

Obstetrical emergencies

Answer 74

urgent clinical situations that place either the maternal or fetal status at risk for increased morbidity and mortality.

Question 75

Tools for obstetrical emergencies

Answer 75

● Availability of appropriate emergency supplies in a resuscitation cart (crash cart) or kit ● Development and implementation of a rapid response team ● Development and implementation of protocols that include clinical triggers ● Use of standardized communication tools for huddles and briefs such as SBAR (situation, background, assessment, recommendation) ● Implementation of emergency drills and simulations

Question 76

Intrapartum Care Communication

Answer 76

assuming the best motives of others, recognizing that we all make assumptions that reflect our own worldviews, seeking first to understand others’ views and then to be understood, and avoiding stereotyping.

Question 77

Shoulder dystocia

Answer 77

unpredictable and unpreventable obstetric emergency that places the laboring mother and neonate at risk of injury and complications

Question 78

Risk Factors Associated With Shoulder Dystocia

Answer 78

● Fetal macrosomia (weight greater than 4,500 grams) ● Maternal diabetes ● History of shoulder dystocia ● Prolonged second stage ● Excessive weight gain

Question 79

Shoulder Dystocia risks mom

Answer 79

severe perineal lacerations, including fourth-degree lacerations, maternal symphyseal separation and peripheral neuropathy, sphincter injuries, infection, bladder injury, or postpartum hemorrhage

Question 80

Shoulder Dystocia risks baby

Answer 80

● Delay in delivery of the shoulders results in compression of the fetal neck by the maternal pelvis ● Most shoulder dystocia cases are alleviated without injury to the fetus.

Question 81

Prolapse of the umbilical cord

Answer 81

occurs when the cord lies below the presenting part of the fetus

Question 82

Prolapse of the umbilical cord risks baby

Answer 82

● Total or partial occlusion of the cord-hypoxia ● Malpresentation of the fetus (such as breech), fetal anomalies, intrauterine growth restriction and small for gestational age (IUGR/SGA), unengaged presenting part

Question 83

Prolapse of the umbilical cord risk factors

Answer 83

● Artifical rupture of membranes | ● Polyhydramnios, multiple gestation, spontaneous ROM, preterm ROM, and grand multiparity

Question 84

Vasa previa

Answer 84

fetal vessels unsupported by placenta or umbilical cord traverses the membranes over the cervix.

Question 85

Risk Factors for Vasa Previa

Answer 85

● Low-lying placenta or a placenta previa ● Pregnancies in which the placenta has accessory lobes ● Multiple gestation ● Pregnancies resulting from in vitro fertilization

Question 86

Risks Associated With Vasa Previa

Answer 86

● Fetal asphyxia from cord compression ● Fetal death from exsanguination

Question 87

Rupture of the Uterus

Answer 87

partial or complete tear in the uterine muscle.

Question 88

Risks Associated With Rupture of the Uterus

Answer 88

●woman and fetus include hypovolemic shock, infection, hypoxemia, acidosis, neurological damage, and possible death ● Maternal complications are primarily due to hypovolemia as a result of hemorrhage. ● Complications to the fetus may be due to uteroplacental insufficiency, placental abruption, cord compression, asphyxia, and/or hypovolemia.

Question 89

hypovolemia

Answer 89

a decrease in the volume of blood in your body, which can be due to blood loss or loss of body fluids.

Question 90

Rupture of the Uterus s/s

Answer 90

● Severe tearing sensation, burning or stabbing pain, and contractions ● Uterine tachysystole and/or hypertonus and vaginal bleeding ●mom-signs and symptoms of hypovolemic shock ●baby- response is related to hemorrhage and placental separation ● Ascending station of the fetal presenting part

Question 91

Anaphylactic syndrome (amniotic fluid embolism)

Answer 91

It is hypothesized that an embolism forms when the amniotic fluid that contains fetal cells, lanugo, and vernix enters the maternal vascular system. In some patients, this can trigger an anaphylactic reaction that results in cardiorespiratory collapse. mortality rate 61-86% and most who survive have brain damage

Question 92

Risk Factors Associated With Anaphylactoid Syndrome

Answer 92

● Advanced maternal age 35 years or older ● Use of oxytocin for medical induction of labor ● Cesarean delivery ● Placental abnormalities (e.g., previa, abruption) ● Uterine rupture ● Assisted operative vaginal delivery (vacuum, forceps) ● Eclampsia ● Polyhydramnios ● Cervical laceration

Question 93

Risks Associated With Anaphylactoid Syndrome

Answer 93

● Adult respiratory distress syndrome ● Heart failure ● DIC ● Multisystem organ failure

Question 94

Disseminated intravascular coagulation (DIC)

Answer 94

a condition that prevents your body from controlling blood clotting and bleeding. Initially, blood clots form in many areas of your body.

Question 95

Disseminated Intravascular Coagulation

Answer 95

syndrome that occurs when the body is breaking down blood clots faster than it can form a clot. This quickly depletes the body of clotting factors, leading to hemorrhage, and can rapidly lead to maternal death.