Week 6 Flashcards
Birthing complications
1
Q
Three types of cephalic presentation are
A
vertex, brow and face
2
Q
Indication for external cephalic version
A
breech position to reposition to vertex
3
Q
what are some ways you can assess before you do an external cephalic version?
A
Ultrasound and Leopold maneuver
4
Q
what is the medical management for external cephalic version?
A
US, informed consent,
tocolysis (meds),
neuraxial analgesia,
NST or BPP,
cesarean services must be readily available
5
Q
what are some risks to external cephalic version?
A
Placental abruption, umbilical cord prolapse, ROM, still birth, fetomaternal hemorrhage, severe variable decelerations
6
Q
What is the procedure in which the fetus is rotated from the breech to the cephalic presentation?
A
External cephalic version
7
Q
When is local anesthesia injected?
A
Second stage of labor, immediately before delivery Anesthetizes local tissue for episiotomy and repair
8
Q
what are contraindications to external cephalic version?
A
Placental abnormalities because it can result in hemorrhage or cord prolapse
9
Q
Where is local anesthesia injected?
A
Anesthetic injected into perineum at episiotomy site
10
Q
What would you monitor for when someone has a regional block?
A
Return of sensation
Increased welling
s/s of infection
urinary retention
11
Q
What are some adverse risks to local anesthesia?
A
Risk of a hematoma
Risk of infection
12
Q
When would you give a regional block?
A
Anesthetize vulva, lower vagina and part of perineum for episiotomy and use of low forceps
13
Q
Where is a regional block placed?
A
Pudendal nerve near the ischial spines
14
Q
When is the epidural block injected?
A
First stage and/or second stage of labor
15
Q
What are some adverse risks to regional anesthesia?
A
Risk of a hematoma
Risk of infection
Risk of local anesthetic toxicity
16
Q
What is the anesthetic injected in the pudendal nerve (close to the ischial spines) via needle guide known as “trumpet”
A
Regional
17
Q
Where is the epidural block injected?
A
Spot outside dura mater between the dura and spinal canal via an epidural catheter
18
Q
What is the most common complication of epidural?
A
Hypotension
19
Q
what are some side effects of an epidural?
A
Nausea, vomiting, pruritis, respiratory depression, alterations and fetal heart rate
20
Q
What are some pre-anesthesia care?
A
Obtain consent. Check lab values—especially for bleeding or clotting abnormalities, platelet count. IV fluid bolus with normal saline or lactated Ringer’s. Ensure emergency equipment is available. Do time-out procedure verification
21
Q
What are some post-anesthesia care?
A
Monitor maternal vital signs and FHR every 5 min initially and after every re-bolus then every 15 minutes and manage hypotension or alterations in FHR.
Urinary retention is common and catheterization may be needed. Assess pain and level of sensation and motor loss. Position woman as needed
Assess for itching, nausea and vomiting, and headache and administer meds PRN.
When catheter discontinued, note intact tip when removed.
22
Q
What are indications for general anesthesia?
A
Risk for fetal depression
Risk for uterine relaxation
Risk for maternal vomiting and aspiration
23
Q
What about anesthesia might be passed into the infant?
A
Fetal acidemia
24
Q
lack of continuing progress toward birth for _(time)__ with regional anesthesia or _(time)__ without regional analgesia or
anesthesia and for multiparous women as a lack of
continuing progress for _(time)__ with regional anesthesia or _(time)__ our without regional anesthesia.
A
3, 2
2, 1
25
What is a main reason for amnioinfusion?
Intrauterine resuscitation interventions?
26
What FHR can amnioinfusion correct? How?
Variable decelerations by correcting cord compression from oligohydramnios
27
what is the procedure we're where room temperature saline or lactated ringer is infused into the uterus transcervically via an IUPC to increase amniotic fluid to cushion the biblical cord and reduce compression?
Amnioinfusion
28
what is the medical management of variable decelerations?
Amnioinfusion, tocolytics, and delivery
29
What is the leading indication for primary cesarean birth in the US?
Labor distocia
30
abnormal labor results from abnormalities of what three p’s?
Power, passenger, pelvis
31
what is it called when there is abnormal uterine contractions that prevent normal progress of cervical dilation or descent of the fetus?
Dysfunctional labor
32
what are two practical classifications of abnormal labor in the active phase?
Protraction disorders where there is slower than normal labor
Arrest disorders with complete cessation of uterine contractions
33
what are some risk factors for dystocia?
Congenital uterine abnormalities such as bicornuate uterus
male presentation of a fetus such as occiput posterior or face presentation
cephalopelvic disproportion
tachysystole the uterus with oxytocin
Maternal fatigue and dehydration
Administration of analgesic or anesthesia early in labor
Extreme maternal fear or exhaustion which can result in catecholamine release interfering with contractility
34
what are two types of uterine dystocia?
Hypotonic uterine dysfunction
hypertonic uterine dysfunction
35
what is the term for uncoordinated uterine activity where contractions are frequent and painful but ineffective in promoting dilation and effacement?
Hypertonic uterine dysfunction
36
what is it called when there is ineffective contractions during early labor?
Prodromal labor
37
what are the causing risk factors of hypertonic uterine dysfunction?
nulliparous women
38
what are some risk factors related to hypertonic uterine dysfunction to the fetus?
Intolerance of labor
Asphyxia related to decreased placental perfusion
39
what are some findings for hypertonic uterine dysfunction?
Painful frequent uterine contractions
Inadequate uterine relaxation between contractions
Little cervical changes
May be category two or category 3
40
what are some nursing actions for hypertonic uterine dysfunction?
Promote rest to break the pattern of contractions
administer demerol or morphine to promote sleep and prevent exhaustion
hydrate
warm shower or tub bath
Quiet environment
41
what is it called when the pressure of contractions is insufficient and less than 25mm Hg?
Hypotonic uterine dysfunction
42
what is the strength of contractions to have sufficient pressure to promote cervical dilation and Effacement?
25 or more
43
what are some causes or risk factors that increase the chance of hypotonic uterine dysfunction?
Multiparous womaen
Extreme fear which can release catecholamine
44
what are the assessment findings for hypotonic uterine dysfunction?
what are the assessment findings for hypotonic uterine dysfunction?
45
what are some medical managements for hypotonic uterine dysfunction?
Determine the cause
Augment with oxytocin
Perform amniotomy
Perform cesarean when other interventions have failed
46
what are some nursing actions for hypotonic uterine dysfunction?
Assess contractions and maternal and fetal status
ambulate and change position to promote comfort
Hydrate with Ivy or PO as dehydration can cause dysfunctional labor
Administer IV fluids to correct maternal hypotension
augment with oxytocin
47
why is it important to not do a sterile exam and maintain perineal cleanliness during prolonged labor?
There is a risk of infection with prolonged labor
48
how frequently do hypertonic uterine contractions happen and last for?
Occurs every two minutes or more frequently lasting greater than 60 seconds and strong
49
how would you describe contractions occurring every 2 minutes or more frequently lasting greater than 60 sec and strong
Occurs every two minutes or more frequently lasting greater than 60 seconds and strong
50
how would you describe contractions occurring every 2 minutes or more frequently lasting greater than 60 sec and strong
hypertonic or tetanic uterine contractions
51
how would you categorize rapid cervical dilation that labor is less than three hours?
precipitous labor
52
how often should you check contractions and fetal heart rate during a precipitous labor and birth?
Every 15 minutes
53
Precipitous labor places the woman at risk for what?
Postpartum hemorrhage related to uterine anatomy or lacerations
54
What are some risks to the fetus of precipitous labor?
Hypoxia and risk for CNS depression
55
What should you do as a nurse to prepare for a precipitous labor?
Remain in the room who are having rapid birth
anticipate potential complications such as hemorrhage and lacerations
assess dilation and contractions
anticipate potential neonatal complications such as hypoxia and CNS depression
56
Why might a fetus have hypoxia with precipitous labor?
Uterine contractions are strong
57
What is the difference between induction and augmentation
Induction is deliberate stimulation of contractions before spontaneous labor has started. And augmentation needs assessment when spontaneous contractions have not resulted in progressive cervical dilation or descent
58
Fetal dystocia may be caused by what factors?
excessive fetal size (4,500g+)
malpresentation like face, brow, or breech
multifetal pregnancy
fetal anomalies like hydrocephalus
59
What is the best position for the baby to be born?
Head flexed
Presenting anterior to the women’s pelvis (occiput anterior position)
60
Complications of fetal dystocia are:
■ Neonatal asphyxia related to prolonged labor
■ Fetal injuries, such as bruising
■ Maternal lacerations
■ Cephalopelvic disproportion (CPD)
61
What fetal anomalies can cause fetal dystocia?
Hydrocephalus
62
what kind of fetal presentation puts the baby at risk for fetal dystocia?
Brow, face, breach
63
What is the normal anteroposterior diameter?
14 cm
64
occiput posterior can cause what to the mother?
Prolong labor and prolonged second stage
severe back pain
65
a condition in which the size, shape, or position of the fetal head prevents it from passing through the lateral aspect of the maternal pelvis or when the maternal pelvis is of a size or shape that prevents the descent of the fetus through the pelvis
Cephalopelvic disproportion
66
Cephalopelvic disproportion is a condition in which the _____, _____, or ____ of the fetal head prevents it from passing through the ____ aspect of the maternal pelvis or when the maternal pelvis is of a size or shape that prevents the descent of the fetus through the pelvis
size, shape, or position
lateral
67
babies born before completed 37 weeks are at risk for what complications?
Prematurity
Cesarean
Hemorrhage
Infection
Breathing problems
Feeding issues
Jaundice
Low blood sugar
Insufficient stabilizing their own body temperature
68
what cascade of interventions does induction of Labor lead to?
IV fluids
Activity restriction or bed rest
More frequent or continuous fetal monitoring
Increased pain medication use and epidural anesthesia
Amniotomy
Prolonged stay in the labor unit
69
what are some things to consider when choosing a induction versus spontaneous labor
parity
Status some membranes
Status of cervix
History of previous cesarean births
70
Contras for oxytocin induction
■ Any contraindications for vaginal birth
■ Previous vertical (classical) uterine scar or prior transfundal uterine scar
■ Placental abnormalities such as complete placenta previa or vasoprevia
■ Abnormal fetal position
■ Umbilical cord prolapse
■ Active genital herpes
■ Pelvic abnormalities
71
Risks Associated With Inductions
Tachysystole leading to Category II (indeterminate) or Category III (abnormal) FHR pattern ( primary complication)
Side effects of oxytocin use are primarily dose related
tachysystole and subsequent FHR decelerations are common side effects
Water intoxication can occur with high concentrations of oxytocin with large quantities of hypotonic solutions
72
A uterine response occurs to oxytocin in ____minutes, with a half-life of __ minutes.
3–5, 10
73
What is the most common induction agent?
oxytocin
74
what are some medical indications of the mother that can result in oxytocin induced labor?
Diabetes, renal disease, chronic pulmonary disease, cardiac disease, chronic hypertension
75
what are some indications not related to the mother's health that results in oxytocin induced labor?
Post term pregnancy,
Preeclampsia
premature rupture of membranes
Chorioamnionitis
Fetal stress or compromise such as IUGR and oligohyd.
Fetal demise
History of rapid labors/distance from hospital
Psychosocial considerations
76
It is estimated that ___%–___% of inductions are elective or nonmedical.
25%–50%
77
Side effects of oxytocin use are typically caused by what?
Dosing problems
78
What is the goal of administering oxytocin in labor
goal of oxytocin use in labor is to establish uterine contraction patterns that promote cervical dilation of about 1 cm/hr once in active labor.
79
Oxytocin is administered ________ and is _______ to a ________at the port most _______ to the venous site
Intravenously
Piggybacked
mainline IV solution
proximal
80
Oxytocin is ____ infused via a _____
Always
Pump
81
When should oxytocin be stopped?
Once active labor is established, oxytocin should be discontinued to avoid downregulation.
82
where is endogenous oxytocin synthesized and released?
In the hypothalamus that is transported into the posterior lobe of the pituitary glandTrue
83
Prior to elective induction, fetal maturity must be confirmed to be _____ weeks or greater by the following:
39
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.
84
Avoid ____ because it frequently results in _______or _____fetal heart rate pattern.
Tachysystole
Category II or III
85
What are nursing actions for a Category II or Category FHR pattern from oxytocin induction?
■ Discontinue.
■ Change maternal position to lateral.
■ Initiate IV hydration of at least 500 mL LR
■ Administer O2 by nonrebreather mask at 10 L/min.
■ Consider terbutaline if no response
■ Notify the provider and request evaluations for Category III abnormal FHR.
86
What is considered tachysystole?
More than 5 UCs in 10 minutes over 30-minute window
Series of single UCs lasting 2 minutes or longer
UCs occurring within 1 minute of each other
87
What two diseases can cause chorioamnionitis?
GBS and Bacterial vaginosis
88
GBS and Bacterial vaginosis
intrauterine inflammation or Triple IClar without a clear source
89
What is chorioanmiontis aka?
intrauterine inflammation or Triple I
90
What is suspected Triple I?
at term of pregnancy can have an infectious and/or inflammatory origin and is associated with adverse outcomes
91
What are some complications of chorioamnionitis in fetus?
acute neonatal morbidity like neonatal pneumonia, meningitis, sepsis, and death,
long-term infant complications such as bronchopulmonary dysplasia and cerebral palsy
92
What are suspected Tripe I results?
Baseline fetal tachycardia (greater than 160 beats per minute [bpm] for 10 minutes or longer, excluding accelerations, decelerations, and periods of marked variability) Maternal WBC counts greater than 15,000 per mm3 in the absence of corticosteroids Definite purulent fluid from the cervical os
93
Risk factors that can cause chorioamnionitis
Migration of cervicovaginal flora through the cervical canal
Prolonged ROM lasts greater than 24 hours.
Low parity
multiple digital examinations
use of internal uterine and fetal monitors
meconium-stained amniotic fluid, and presence of genital tract pathogens
94
What temperature is an isolated maternal fever?
Oral temp of 102.2 F or greater on any one occasion
95
Characteristic clinical signs of chorioamnionitis:
Maternal fever (intrapartum temperature higher than 100.4°F [37.8°C])
Significant maternal tachycardia (greater than 120 bpm) Fetal tachycardia (greater than 160 to 180 bpm)
Purulent or foul-smelling amniotic fluid or vaginal discharge Uterine tenderness
Maternal leukocytosis (total blood leukocyte count greater than 15,000 to 18,000 cells/μL)
Hypotension Diaphoresis Cool or clammy skin
96
What is a positive Triple I
Amniocentesis-proven infection through a positive Gram stain Low glucose or positive amniotic fluid culture Placental pathology revealing diagnostic features of infection
97
What stimulates prostaglandin release resulting in cervical ripening?
Inflammatory cytokines or bacterial endotoxins
98
What is the medical management of chorioamnionitis?
Communicate about any abnormal v/s
Abx
antipyretics.
99
What is the test used for cervical status?
Bishop score
100
What is the process of physical softening, thinning, and dilating of the cervix in preparation for labor and birth
Cervical ripening
101
What are the three changes that happens to the cervix to prepare for labor and birth.
ripening, effacement, and dilation
102
What is a favorable cervix according to the Bishop score?
8 or more
103
What is an unfavorable cervix according to the Bishop score?
6 or less
104
What are some mechanical cervical ripening?
hygroscopic dilators (laminaria, Lamicel, or Dilapan) transcervical balloon catheters (Cook balloon or deflated Foley catheter)
105
Cervical ripening is associated with a higher risk of __________ when labor is induced compared with spontaneous labor
cesarean delivery
106
Pharmacological methods of cervical ripening
cervidil (dinoprostone insert)
misoprostol PGE1 (cytotec)
107
What are the indications of mechanical cervical ripening?
When the woman has little or no cervical effacement When pharmacological methods are contraindicated, such as women with prior uterine incision
108
What might happen if a woman has a Bishop score of less than six?
Might use a cervical ripening procedure
109
How long after using dinoprostone gel would oxytocin be delayed?
6-12 hours after
110
Risks Associated With Mechanical Cervical Ripening
Higher rate of infection
PROM
111
How long does a mechanical dilator stay in place?
6-12 hours before removal or assessment
112
Contraindications for mechanical cervical ripening
Active herpes
Unexplained vaginal bleeding
Placenta previa
Vasa previa
Ruptured membranes
Prior c-section
113
How long after misoprostol should oxytocin be delayed?
At least four hours
114
What kind of hormone is used for pharmacological methods of cervical ripening?
Prostaglandins
115
How long after cervidil removal can the woman be given oxytocin?
30-60 minutes
116
Contraindications for pharmacological cervical ripening
Vertical uterine incision
Active herpes
Baby in breech position
117
What are the four risks for amniotomy
variable decelerations
bleeding
umbilical cord prolapse
intraamniotic infection
118
What are the two cervical ripening agents that are no recommended for women with a previous uterine scar?
Insertable cervidil
Misoprostol pge
119
What is AROM?
Artificial Rupture of Membranes
120
What is AROM used for?
used to induce or augment labor during a sterile vaginal exam, or shorten labor
121
Amniotomy in early labor increases the risk of _____ for __________.
cesarean birth
abnormal FHR
122
What do you assess immediately after AROM?
FHR and UC
Color, amount, and odor of amniotic fluid
cervical status and fetal station
temperature every two hours
123
AROM is most effective in multiparous women who are __________.
dilated to 2 cm or more.
124
What is labor augmentation
stimulation of ineffective UCs after the onset of spontaneous labor to manage labor dystocia
125
What are contraindications to amniotomy and why?
■ Fetal head not engaged in the maternal pelvis (cord prolapse)
■ Maternal infection such as HIV and active genital herpes (infection)
126
Vacuum cup should not be on the fetal head for longer than ____
15-20 minutes
127
What are some things to confirm before vacuuming?
Cervix fully dilated and retracted
Membranes ruptured
Engagement of the fetal head
Position of the fetal head has been determined
Weight estimated
Adequate anesthesia
Pelvis is adequate
Fetus older than 34 wks, engaged head, and at least 0 station
128
Indications to forceps use
Fetal head Is engaged and cervix dilated
No suspicion of immediate or potential fetal compromise
To shorten 2nd stage for maternal benefit
Prolonged second stage
High level of regional anesthesia
Maternal cardiac of pulmonary disease
129
What is the stimulation of ineffective UCs AFTER the onset of spontaneous labor to manage labor dystocia
Labor augmentation
130
What are some advantages of vacuum over forceps?
Easier application
Less anesthesia required
Less maternal soft tissue damage
Fewer fetal injuries
131
Forceps risk for newborn
facial lacerations
facial nerve palsy
corneal abrasions and external ocular trauma
skull fracture
intracranial hemorrhage/subdural hematoma
132
facial lacerations
facial nerve palsy
corneal abrasions and external ocular trauma
skull fracture
intracranial hemorrhage
facial lacerations
facial nerve palsy
corneal abrasions and external ocular trauma
skull fracture
intracranial hemorrhage
133
How often do you assess the temperature after an anmiotomy?
Every two hours
134
What are some indications for vacuuming?
maternal exhaustion and an inability to push effectively
medical indications such as maternal cardiac disease and a need to avoid pushing in the second stage of labor
prolonged second stage of labor (nulliparous woman with lack of progress for 3 hrs w/ anes or 2 w/o anes.
arrest of descent, or rotation of the fetal head
nonreassuring FHR patterns in the second stage of labor
135
Risks for the Newborn with vacuum
Cephalohematoma (15%
Laceration
Subgaleal or intracranial, or retinal hemorrhage
Increased rates of hyperbilirubinemia
136
Low forceps are used in what instance?
Areused when the skull is at +2 station or lower in the maternal pelvis and not on the pelvic floor and rotation is greater than 45 degrees (
137
Amniotic fluid embolism (AFE), also known as
anaphylactic syndrome
138
Amniotic fluid is made up of what?
maternal extracellular fluid, fetal urine, fetal squamous cells, lanugo, vernix caseosa, mucin, meconium, arachidonic acid metabolites, and, late in pregnancy, increased concentrations of prostaglandins
139
What are the guidelines for vacuum application?
Engaged fetal head and complete dilation
Maximum of three tries in 15 minutes
Cup detachment means warning sign for too much pressure/ineffective force
Proceed when cesarean birth if necessary.
140
What is anaphylactic syndrome?
amniotic fluid that contains fetal cells, lanugo, and vernix enters the maternal vascular system and results in cardio respiratory collapse
141
Risks for the Woman with vacuum
Vaginal and cervical lacerations
Extension of episiotomy (3rd and 4th degree perineal tears)
Hemorrhage related to uterine atony or rupture
Bladder trauma
Perineal wound infection
142
When are outlet forceps used?
when the head is visible on the perineum and the skull has reached the pelvic floor, and rotation is less than 45 degrees
143
When can AFE occur?
during pregnancy, labor, birth, or the first 24 hours postbirth
144
How old must a fetus be to deliver with forceps?
Use only on a fetus that is at least 36 weeks’ gestation
145
Forceps risk for mother
Vaginal and cervical lacerations; risk of 3rd- and 4th-degree perineal tears compared with patients who had a spontaneous delivery.
Extension of episiotomy
Hemorrhage related to uterine atony and uterine rupture.
Perineal hematoma Bladder trauma Perineal wound infection
146
What are the two types of operative vaginal birth?
Vacuum assisted and forceps assisted
147
What is the indication of labor augmentation?
to strengthen and regulate UCs, to shorten length of labor
148
Prolonged second stage for nulliparous woman
lack of continuing progress for 3 hours with regional anesthesia, or for 2 hours without anesthesia
149
Prolonged second stage for multiparous woman
lack of continuous progress for 2 hours with regional anesthesia, or for 1 hour without regional anesthesia
150
What is the ideal goal for contractions induced by oxytocin?
Frequency 2-3 minutes
Intensity 60-90
Duration 45-60 sec
151
amniotic fluid may enter the maternal circulation in what three ways
(1) through the endocervix following rupture of amniotic membranes
(2) at the site of placental separation
(3) at the site of uterine trauma, often lacerations that occur during normal labor, fetal descent, and birth (placental abruption for example)
152
Why should you have two IV sites for AFE?
One for blood and one for fluids
153
AFE classically consists of hypoxia from _____ and ________,________, and ________, and ________,
acute lung injury and transient pulmonary hypertension, hypotension, and cardiac arrest and coagulopathy
154
What does a sudden presentation of dyspnea lead to in anaphylactic syndrome?
Massive fibrinolysis
155
AFE can lead to what in the mother?
Postpartum hemorrhage with severe DIC
Hypoxic encephalopathy
156
Signs and symptoms of anaphylactoid syndrome are related to _____ and _______.
anaphylactic shock
cardiopulmonary collapse
157
anaphylactoid reaction leads to what complications
Acute pulmonary hypertension
Rt and lt. ventricular failure
Acute respiratory failure
DIC
158
sudden hypoxemia and shock can evolve rapidly into what?
Cardiorespiratory collapse
159
Risk factors of AFE?
older maternal age
multiple pregnancy
placenta previa
labor induction
cesarean delivery
instrumental vaginal delivery
cervical or uterine trauma
eclampsia
160
What is in stage one of AFE?
Amniotic fluid and fetal cells enter the maternal circulation → release of endogenous mediators → pulmonary vasospasm and pulmonary hypotension → elevated right ventricular pressure and hypoxia → myocardial and pulmonary capillary damage → left heart failure and acute respiratory distress
161
How would you recognize AFE?
rapid onset of respiratory distress during labor, delivery, or 30 minutes postdelivery
severe hypoxia; hypotension; cyanosis; loss of consciousness
foaming at the mouth
pulmonary edema
uncontrolled bleeding from the uterus, IV sites, or any other incisions due to coagulopathy
seizures, cardiac arrest
prolonged late decelerations or bradycardia
162
What is in stage two of AFE?
Hemorrhage and DIC
163
Medical management of AFE
V
164
entry points of amniotic fluid are:
Cervix following rupture of amniotic membranes
Site of placental separation
Site of uterine trauma—lacerations that occur during the labor and delivery process
165
VBAC may decrease the risk of what maternal consequences related to multiple cesarean deliveriesWhat are VBAC indication?
Hysterectomy
bowel or bladder injury
transfusion
infection
abnormal placentation such as placenta previa and placenta accreta
166
What is the opportunity to achieve a VBAC called?
trial of labor after cesarean (TOLAC)
167
Women with what have a higher rate of failed VBAC and infection.
obesity
168
What are VBAC indication?
One or two prior low transverse cesarean births with no other uterine scars
Clinically adequate pelvis
Physician and OR team immediately available to perform emergent cesarean birth.
169
Health advantages of VBC
lower rates of hemorrhage, thromboembolism and infection
shorter recovery
170
Contraindications of VBAC
Prior vertical (classical) or T-shaped uterine incision or other uterine surgery
Previous uterine rupture
Pelvic abnormalities
Medical or obstetric complications that preclude a vaginal birth
Inability to perform an emergent cesarean birth if necessary because of insufficient personnel such as surgeons, anesthesia, or facility
171
Benefits of TOLAC resulting in VBAC include
Shorter hospital stays and postpartum recovery
Fewer complications, such as postpartum fever, wound or uterine infection, thromboembolism, and transfusion.
Fewer neonatal breathing problems
172
Women with epidurals may feel ____ and ____ during the procedure because epidurals are not as _____ and do not provide full _____ and _____ _____.
Tugging, pulling
Dense
Sensory and motor block
173
Which is the “bikini cut” incision?
Pfannenstiel incision where ; transverse skin incision made at the level of the pubic hairline
174
What are some expected finding of the patient during a c-section?
Increased anxiety levels
Concerns related to potential injury from anesthesia and or surgery
Woman may feel abdominal pressure as the neonate is being delivered
175
Risks Associated With VBAC
Uterine rupture and complications w/ rupture
Failed TOLAC is associated with more complications than elective repeat cesarean delivery.
Uterine rupture or dehiscence
Neonatal morbidity is higher in the setting of a failed TOLAC than VBAC
176
Which prior cesarean incision is a contraindication for VBAC and why?
Prior vertical (classical) or T-shaped uterine incision because the uterus can rupture
177
Medical management of c-section preoperative
obtain informed consent
draw labs (CBC, blood type, Rh)
education
178
Experts suggest a TOLAC to attempt a VBAC is an acceptable option for a woman who has undergone ______ delivery with _______ incision
one prior cesarean
a low transverse uterine
179
Waiting for spontaneous labor and avoiding use of ____ and ___ reduces the risk of _____.
prostaglandins and oxytocin
uterine rupture
180
What to review before surgery
History
include patient
family member
support person in plan of care
individualized care
allow 1 support person to be present during surgery
181
What are possible complications of c-sections?
Hemorrhage
Bladder, ureters, and bowel trauma
Maternal respiratory depression related to anesthesia
Maternal hypotension related to anesthesia, which increases the risk for fetal distress
Inadvertent injection of the anesthetic agent into the maternal bloodstream
182
What happens if there is inadvertent injection of the anesthetic agent into the maternal bloodstream?
woman experiences ringing in her ears, metallic taste in her mouth, and hypotension that can lead to unconsciousness and cardiac arrest
183
The determination of type of anesthesia is based on what?
Is the safest and most comfortable for the woman
Has the least effect on the fetus/neonate
Provides the optimal conditions for the surgery
184
Why is spinal anesthesia is the preferred method for scheduled cesarean sections?
Spinal anesthesia, which is faster to place, provides a full sensory and motor block
185
General anesthesia is used for what situations?
Rapid delivery is imperative
Severe hemorrhage
Seizures
Failed Spinal
186
What is a classical cesarean delivery?
vertical abdominal wall skin incision and vertical incision in the body of the uterus
rare, used in emergent cesarean births when immediate delivery is critical
placenta is manually removed
187
Nursing actions 24 hrs postop to discharge
Assess for involutional changes and complications
Monitor v/s every eight hours
Incentive spirometer or deep breath and cough every 2 hrs
Monitor for hemorrhage and infection
Assess fundus and lochia
Remove foley around 8-12 hrs after surgery
188
Contraindications for epidural or spinal anesthesia
The woman’s refusal or inability to cooperate with the procedure
Increased intracranial pressure
Infection at the site of needle insertion
Low platelet count
Uncorrected maternal hypovolemia
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Expected Assessment Findings of c-section
Normal v/s
Lochia is moderate to scant
Firm fundus and midline
Dressing is dry
Catheter is draining clear/yellow
IV has no infiltration or inflammation
Pain is less than 3
Gradually regains full motor and sensory function
Food feeding
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What are some nursing actions preop cesarean?
Assess FHR
Resposition to left lateral tilt
Apply grounding device
Insert foley
Perform abdominal skin prep
Check equipment
191
Immediate postop care of c-section First 24 hours after birth include
IV therapy
Medications such as analgesics and stool softeners
Antibiotic therapy for the woman at risk for infection related to prolonged rupture of membranes, prolonged labor, or elevated temperature during labor
Progression of diet
Removal of the Foley catheter
Activity level
192
What are some SE of morphine?
Itching
Nausea
Decreased respirations
193
How much should a woman void after catheter removal?
200-300 cc
194
What refers to difficulty encountered during delivery of the shoulders after the birth of the head?
Shoulder dystocia
195
What should you do to the infant after a c-section?
Allow the parents to see or touch the baby after it is born, or hold and skin-to-skin if stable
196
It’s when the head goes back against the mother’s perineum after the head has already been delivered
Impaction of the fetal shoulders may lead to a prolonged delivery time of more than _____.
197
Neonatal morbidity of shoulder dystocia includes:
Brachial plexus injuries
Clavicle fracture
Neurological injury
Asphyxia
Death
198
The usual hospital stay for c-section
3-5 days
199
Risk Factors causing Shoulder Dystocia
Fetal macrosomia (wt >4,500 grams)
Maternal diabetes
History of shoulder dystocia
Prolonged second stage
Excessive weight gain
200
What specific part of the shoulders get stuck with shoulder dystocia?
anterior shoulder or, more rarely, both shoulders become impacted above the pelvic rimWhat is a turtle sign?
201
Medical Management of shoulder dystocia
Downward traction may be applied to the fetal head w/ suprapubic pressure
Extend the midline episiotomy to obtain room for maneuvers.
McRoberts maneuver initially
Woods corkscrew maneuver
Deliver the posterior shoulder by sweeping the posterior arm across the fetus’s chest followed by delivery of the arm.
202
What is the Woods corkscrew maneuver?
progressively rotates the posterior shoulder 180 degrees to disimpact the anterior shoulder.
203
Risks Associated With Shoulder Dystocia
Delay in delivery of the shoulders results in compression of the fetal neck by the maternal pelvis, which impairs fetal circulation and results in possible increased intracranial pressure, anoxia, asphyxia, and brain damage.
Brachial plexus injury and clavicle fracture in the neonate can also occur.
Maternal complications include lacerations, infection, bladder injury, or postpartum hemorrhage.
204
Zavanelli maneuver
cephalic replacement into the pelvis and then cesarean delivery, for catastrophic cases only
205
What is the McRoberts maneuver?
Two assistants, each grasp a maternal leg and then sharply flexes the thigh back against the maternal abdomen
Causes cephalad rotation of the symphysis pubis and flattening of the lumbar lordosis that can free the impacted shoulder
206
Why might shoulder dystocia cause asphyxia?
A more than 5- minute delay in head to body interval may result in fetal hypoxemia and acidocis
207
Additional fetal risks of post-term pregnancies include:
macrosomia, which increases the likelihood of operative vaginal deliveries, cesarean deliveries, and shoulder dystocia
neonatal seizures
meconium aspiration syndrome (MAS)
low 5-minute Apgar scores
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When might a c-section be planned to prevent shoulder dystocia?
suspected fetal macrosomia with an estimated fetal weight exceeding 5,000 grams in women without diabetes and 4,500 grams in women with diabetes
209
risk of stillbirth increases beyond ____ weeks.
41
210
Suprapubic pressure in fetal dystocia is what?
Pressure is applied above the pubic bone with the palm or fist and laterally, and then aduct and rotate the anterior shoulder
. Fundal pressure should be avoided to prevent impaction of shoulder and cause uterine rupture
211
What are some nursing actions for a shoulder dystocia?
Insert straight cath if distended
Mother should not push
Notify neonatal team and prepare for neonatal resuscitation
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Which is more common post term? Oligohydramnios or polyhydramnios
Oligohydramnios
213
Meconium-stained fluid occurs in __-__% of post-term pregnancies
25%–30%
214
Oligohydramnios in post term has been associated with what?
Cord compression, GHR abnormalities
meconium-stained amniotic fluid
fetal acidosis
215
What are assessment finding of post-term pregnancy and birth?
Category II or III FHR related to decreased amniotic fluid and uteroplacental insufficiency
Pregnancy with aging placenta
Meconium-stained fluid
Women report increased anxiety and frustration with prolonged pregnancy
Fetal macrosomia
216
Aspiration of meconium results in what complications?
. Aspiration of meconium results in respiratory distress that in severe cases can be life-threatening.
It induces hypoxia via four major pulmonary effects:
airway obstruction
surfactant dysfunction
chemical pneumonitis
pulmonary hypertension
217
Meconium stool begins to form during the ___gestational month and is the first stool eliminated by the neonate. It is ___, ___, ___, and ___. It is first passed within __-__ hours.
4th
sticky, thick, black, and odorless
24-48 hrs.
218
Signs of post-term birth
Still birth or neonatal dea
Macrosomnia
Fetal dysmaturity
Restricted growth
Decreased subcut fat
Lack of vernix and lanugo
Meconium staining of the amniotic fluid, skin, membranes and umbilical cord
219
Post-term medical management
Antenatal surveillance ■ Induction of labor offered at 41 weeks of gestation
220
What are s/s off pulmonary embolism?
dyspnea, tachypnea, chest tightness, shortness of breath, hypotension, and decreasing oxygen saturation levels.
Leg pain can lead to PE
221
What is called when the cord lies below the presenting part of the fetus.
Umbilical cord prolapse
222
Risk factors that cause Prolapse of the Umbilical Cord
Malpresentation of the fetus (such as breech)
Unengaged presenting part
Polyhydramnios
Small or preterm fetus
Multiple gestation
High parity
223
Which condition would you position the patient on hands and knees to help rotate fetus?
Labor dystocia
224
What is Occult prolapse?
cord is palpated through the membranes but does not drop into the vagina
225
Risks Associated With Prolapse of the Umbilical Cord
rapid deterioration in fetal perfusion and oxygenation
226
An entrapped cord can results in what to the FHR?
bradycardia
227
Assessment Findings of umbilical cord prolapse
Sudden fetal bradycardia (i.e., prolonged decelerations) ■ Prolapsed umbilical cord that may be felt with a SVE or visualized in or protruding from the vagina
228
Risk factors r/t pregnancy of cord prolapse:
The primary iatrogenic cause is AROM.
Polyhydramnios
multiple gestation
SROM
preterm ROM
grand multiparity
229
Medical Management of cord prolapse
Vaginal birth or operative vaginal delivery may be attempted if birth is imminent.
c-section
230
Nursing Actions for prolapsed cord
hand remains in the vagina, lifting the presenting part off the cord until delivery by cesarean
Recommend position changes such a knee-chest position or Trendelenburg to try to relieve pressure
O2
Discontinue oxytocin
IV fluid hydration bolus
Administer tocolytic
231
Risks with umbilical cord prolapse
rapid deterioration in fetal perfusion
oxygenation
fetal hypoxia; if not treated swiftly,
long-term sequela, disability, or death
232
Overt vs occult prolapse
Occult is not visible nor palpable and with over, the cord presents before the fetus and is visible or palpable within the vagina or past the labia
233
In which condition would you have the mom in a knee-chest or Trendelenburg
Prolapsed umbilical cord
234
Which condition would you call for assistance?
Prolapsed cord, uterine rupture
235
In which condition would you encourage the patient to remain in a side-lying position
Precipitous labor
236
Which condition would you administer oxygen?
Uterine rupture and prolapsed umbilical cord
237
Prolapse of the umbilical cord can lead to compression, causing FHR _______including severe sudden _____; this often occurs with prolonged ______or recurrent moderate-to-severe ___ decelerations.
Decelerations
Deceleration
Bradycardia
variable
238
For which condition would you monitor for signs of maternal hemorrhage or postpartum hemorrhage?
Precipitous labor, and uterine rupture
239
What is associated with postpartum hemorrhage that can lead to
Increased morbidity and mortality rates are associated with postpartum hemorrhage, which can result in the need for emergency hysterectomy, hypovolemic shock, disseminated intravascular coagulation, and renal and hepatic failure.
240
For which condition would you assist with amniotomy?
Labor dystocia
