Lecture 9 Labor and birth complications

Question 1

Placenta previa

Answer 1

1. Implantation of the placenta in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces.
2. Unique features: Painless, bright red vaginal bleeding; fundal height greater than expected for gestational age; fetus is commonly transverse, breech or oblique with a high, non-engaged presenting part.
3. Cesarean birth is preferable.

Question 2

Complete placenta previa

Answer 2

Placenta previa in which the placenta totally covers the internal cervical os.

Question 3

Marginal placenta previa

Answer 3

Placenta previa in which the edge of the placenta is seen on transvaginal ultrasound to be less than 2.5 cm or closer to the internal cervical os.

Question 4

Low-lying placenta

Answer 4

1. Placenta previa in which the exact relationship of the placenta to the internal cervical os has not been determined.
2. Apparent placenta previa in the second trimester.

Question 5

Placenta previa is commonly diagnosed using _

Answer 5

A transvaginal ultrasound.

Question 6

The major maternal complication associated with placenta previa is _, and in some cases _ may be necessary.

Answer 6

Hemorrhage; a hysterectomy.

Question 7

“Expectant management” refers to _

Answer 7

Observation and bed rest (“watchful waiting”).

Question 8

For a patient with placenta previa experiencing signs of preterm labor, _ can be administered for tocolysis.

Answer 8

Magnesium sulfate.

Question 9

Abruptio placentae

Answer 9

1. The detachment of part or all of a normally implanted placenta from the uterus (premature separation of the placenta; placental abruption). Marked by painful, dark red vaginal bleeding.
2. Difficult to diagnose - sometimes seen as a retroplacental mass on an ultrasound; hypofibrinogenemia and evidence of DIC support the diagnosis. Should be highly suspected in the woman who experiences a sudden onset of intense, usually localized, uterine pain, with or without vaginal bleeding.
3. Vaginal birth is preferable.

Question 10

Placental abruption - grade 2 moderate separation (20%-50%)

Answer 10

Absent to moderate vaginal bleeding, 1000-1500 mL total blood loss, painful, increased uterine tone, gestational or chronic hypertension commonly present. Abnormal FHR and pattern.

Question 11

Placental abruption - grade 3 severe separation (>50%)

Answer 11

Absent to moderate vaginal bleeding, >1500 mL total blood loss, agonizing, unremitting uterine pain, tetanic, persistent uterine contractions with boardlike uterus, DIC frequently present, shock is common and may occur suddenly, gestational or chronic hypertension commonly present. Abnormal FHR and pattern. Fetal death can occur.

Question 12

Couvelaire uterus

Answer 12

Associated with placental abruption; occurs when blood accumulates between the separated placenta and the uterine wall. The uterus appears purple or blue rather than its usual “bubblegum pink” color, and contractility is lost.

Question 13

A positive Apt test result indicates _

Answer 13

Blood in the amniotic fluid.

Question 14

Kleihauer-Betke (KB) test

Answer 14

May be ordered in cases of placental abruption; determines the presence of fetal-to-maternal bleeding. Does not diagnose placental abruption but is useful for purposes of guiding RhoGAM administration.

Question 15

Fetal concerns related to placental abruption

Answer 15

1. The two primary risks to the fetus are IUGR and preterm birth.
2. Corticosteroids are given to accelerate fetal lung maturity.

Question 16

Vasa previa

Answer 16

1. Occurs when fetal vessels lie over the cervical os and are implanted into the fetal membranes rather than into the placenta.
2. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. The umbilical blood vessels thus are at risk for laceration at any time, but laceration occurs most frequently during ROM.

Question 17

Disseminated intravascular coagulation (DIC)

Answer 17

1. A pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both and clotting.
2. Obstetric population - most often triggered by the release of large amounts of tissue thromboplastin, which occurs in placental abruption.
3. Lab findings: Decreased platelets, presence of fibrin split products, prolonged PT and PTT.

Question 18

In caring for the woman with DIC, which order should the nurse anticipate?

Answer 18

Administration of blood. [Primary medical management in all cases of DIC involves a correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters.]

Question 19

Preterm birth

Answer 19

Any birth that occurs before 37 0/7 weeks gestation.

Question 20

Low birth weight

Answer 20

An infant born weighing 2500 g or less.

Question 21

The most common cause of spontaneous preterm labor is _

Answer 21

Infection: Bacterial cervical or urinary tract infections; infection of the amniotic fluid, placenta, and membranes; periodontal disease.

Question 22

Magnesium sulfate (neuroprotection)

Answer 22

1. Administered for fetal neuroprotection against cerebral palsy in women anticipating preterm birth at less than 32 weeks of gestation.
2. Also administered on a short-term basis (up to 48 hours) from 24 to 34 weeks in conjunction with betamethasone for lung maturity.

Question 23

Major interventions for preterm labor

Answer 23

1. Transfer of the mother before birth to a hospital equipped to care for her preterm infant.
2. Giving antibiotics during labor to prevent neonatal group B streptococci infection.
3. Administering glucocorticoids to prevent or reduce infant respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis.
4. Administering magnesium sulfate to women giving birth before 32 weeks of gestation to reduce the incidence of cerebral palsy in their infants.

Question 24

Tocolytic agents

Answer 24

Medications given to arrest labor after uterine contractions and cervical change have occurred. Rationale for use is to allow time for maternal transport and for corticosteroids to reach maximum benefit for the neonate.

1. Magnesium sulfate.
2. Terbutaline (Brethine), ritodrine - β₂-adrenergic agonists.
3. Nifedipine (Procardia) - a calcium-channel blocker.
4. Indomethacin (Indocin) - a NSAID.

Question 25

Magnesium sulfate (tocolysis)

Answer 25

*Antitode: Calcium gluconate.* Administration is IVPB 40 g in 1000 mL (rarely IM); loading dose of 4-6 g/20-30 min.; maintenance dose of 1-4 g/hr. Nursing considerations: Assess for respiratory depression - respiratory rate should be at least *12 breaths/min*; monitor DTRs; should not be given to women with myasthenia gravis.

Question 26

Terbutaline (Brethine)

Answer 26

Administration is SQ 0.25 mg every 4 hours. Nursing considerations: Should not be used in women with a history of cardiac disease, diabetes, preeclampsia with severe features or eclampsia. *Reversal agent for adverse cardiovascular effects: Propranolol (Inderal).*

Question 27

All women between 24 and 34 weeks of gestation who are at risk for preterm birth within 7 days should receive treatment with _

Answer 27

A single course of antenatal glucocorticoids. Optimal benefit to the fetus begins 24 hours after the first injection.

Question 28

Betamethasone and dexamethasone

Answer 28

1. Antenatal glucocorticoids - stimulate fetal lung maturity by promoting release of enzymes that induce production or release of lung surfactant. 2. Maternal side effects: Transient increase in WBC count; hyperglycemia.

Question 29

Preterm premature rupture of membranes (PPROM)

Answer 29

1. Membrane rupture before 37 0/7 weeks gestation; *infection of the urogenital tract* is a major risk factor. 2. Most common complication: Chorioamnionitis (due to the ascent of normal vaginal flora into the amniotic cavity). 3. Managed with *induction of labor* if occurs between 34 and 36 weeks, or as early as 32 weeks if pulmonary maturity can be documented. *Prophylactic broad-spectrum antibiotics* (e.g., ampicillin) given to minimize infection.

Question 30

Macrosomia

Answer 30

Birth weight more than 4000 g; occurs when the placenta continues to provide adequate nutrients to support fetal growth after 40 weeks of gestation.

Question 31

Postterm pregnancy

Answer 31

1. A pregnancy that has completed 42 weeks of gestation or more from the first day of the last menstrual period. 2. Increased risk of: Oligohydramnios (less than 400 mL of amniotic fluid); cord compression and hypoxemia in the fetus; meconium-stained amniotic fluid.

Question 32

Placental abruption - grade 1 mild separation (10%-20%)

Answer 32

Minimal vaginal bleeding, less than 500 mL total blood loss, usually painless, normal uterine tone, normal FHR and pattern.

Question 33

A woman is having her first child. She has been in labor for 15 hours. A vaginal examination performed 2 hours earlier revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part of the fetus was at station 0; however, another vaginal examination performed 5 minutes ago indicated no changes. What abnormal labor pattern is associated with this description?

Answer 33

Secondary arrest. [With a secondary arrest of the active phase, the progress of labor has stopped. This client has not had any anticipated cervical change, indicating an arrest of labor.]

Question 34

Which statement related to cephalopelvic disproportion (CPD) is the least accurate?

Answer 34

CPD can be accurately predicted. [Unfortunately, accurately predicting CPD is not possible. Although CPD is often related to excessive fetal size (macrosomia), malposition of the fetal presenting part is the problem in many cases, not true CPD. When CPD is present, the fetus cannot fit through the maternal pelvis to be born vaginally. CPD may be related to either fetal origins such as macrosomia or malposition or maternal origins such as a too small or malformed pelvis.]

Question 35

Which statement related to the induction of labor is most accurate?

Answer 35

Is rated for viability by a Bishop score. [Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers or 5 or higher for veterans. Version is the turning of the fetus to a better position by a physician for an easier or safer birth. A TOL is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth.]

Question 36

The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation *could* _

Answer 36

Predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes.

Question 37

Which assessment is least likely to be associated with a breech presentation?

Answer 37

Postterm gestation. [Postterm gestation is not likely to occur with a breech presentation. The presence of meconium in a breech presentation may be a result of pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births.]

Question 38

A pregnant woman’s amniotic membranes have ruptured. A prolapsed umbilical cord is suspected. What intervention would be the nurse’s highest priority?

Answer 38

Placing the woman in the knee-chest position. [The woman is assisted into a modified Sims position, Trendelenburg position, or the knee-chest position in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.]

Question 39

When would an internal version be indicated to manipulate the fetus into a vertex position?

Answer 39

Second twin from a transverse lie to a breech presentation during a vaginal birth. [Internal version is used only during a vaginal birth to manipulate the second twin into a presentation that allows it to be vaginally born. For internal version to occur, the cervix needs to be completely dilated.]

Question 40

What is a maternal indication for the use of vacuum-assisted birth?

Answer 40

Maternal exhaustion. [A mother who is exhausted may be unable to assist with the expulsion of the fetus. The client with a wide pelvic outlet will likely not require vacuum extraction. With a rapid delivery, vacuum extraction is not necessary. A station of 0 is too high for a vacuum-assisted birth.]

Question 41

Bishop score

Answer 41

1. Based on cervical dilation, effacement, consistency, position, and fetal station - *a score of 8 or more indicates high potential for successful induction; score below 8 indicates decreased potential for successful induction*. 2. Score of 8/13 or more indicates the cervix is soft, anterior, 50% or more effaced, dilated 2 cm or more, and the presenting part is engaged.

Question 42

Dose of Cytotec for induction of labor

Answer 42

25 mcg.

Question 43

Uterine tachysystole

Answer 43

More than 5 contractions in 10 minutes.

Question 44

Category I FHR tracing - *normal*

Answer 44

Normal FHR; moderate variability; no concerning decelerations; normal accelerations. *Uterine tachysystole - decrease Pitocin by half; if still abnormal after 10 minutes - turn off Pitocin.*

Question 45

Category II FHR tracing - *indeterminate*

Answer 45

Bradycardia not accompanied by absent baseline variability; tachycardia; marked variability; no accelerations in response to fetal stimulation; periodic or episodic decelerations; minimal or absent variability not accompanied by recurrent decelerations. *Turn off Pitocin; consider Terbutaline; reposition mother; oxygen at 10 L/min.*

Question 46

Category III FHR tracing - *non-reassuring*

Answer 46

Non-reassuring FHR patterns associated with fetal hypoxemia; absent baseline variability; recurrent or late decelerations; bradycardia; sinusoidal pattern. *Turn off Pitocin; consider Terbutaline; reposition mother; oxygen at 10 L/min.*

Question 47

Terbutaline (Brethine) causes maternal _

Answer 47

Tachycardia.

Question 48

Nifedipine (Procardia)

Answer 48

Administration is PO 10-20 mg every 3 to 6 hours. A calcium channel blocker that relaxes the uterus to prevent preterm birth; *cannot* be given at the same time as magnesium sulfate.