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What is the primary goal of performing an amnioinfusion?
In what circumstance is internal version performed?
Which nursing care intervention is essential after performing a version on the patient?
What type of episiotomy is preferred for easier repair and better healing?
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What indicates a more severe laceration during childbirth?
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What effect does nipple stimulation have during labor?
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Which of the following is a potential complication associated with amniotomy?
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In the context of labor augmentation, which medication is most commonly used?
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What is the function of transcervical balloon dilators during labor induction?
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What is the primary distinction between induction and augmentation of labor?
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What nursing intervention should be performed if non-reassuring fetal heart patterns occur during oxytocin administration?
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Which Bishop score indicates a better chance for successful labor induction?
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Which of the following is NOT a contraindication for inducing labor?
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What are the indications for inducing labor in a pregnant woman?
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Which nonpharmacologic method may help to stimulate contractions during labor?
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What is a primary indication for using forceps or vacuum extraction during labor?
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Which statement describes a contraindication for using forceps or vacuum extraction?
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What is a primary risk associated with the use of forceps or vacuum extraction during delivery?
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In what scenario would a vacuum extractor be primarily utilized?
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What is a common nursing care intervention following a forceps or vacuum delivery?
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What is the primary purpose of administering prophylactic IV antibiotics before a cesarean section?
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Which uterine incision is preferred for cesarean deliveries because it is less likely to rupture in subsequent births?
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What common emotional reaction may women experience after a cesarean birth?
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Which position should a mother be placed in before surgery to prevent decreased blood flow to the fetus?
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How often should vital signs be assessed after a cesarean delivery during the initial recovery period?
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Which position is recommended for a right occiput posterior presentation to facilitate labor?
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What is the most common soft tissue obstruction during labor?
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Which of the following factors can contribute to prolonged labor?
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Which nursing intervention is most important to support a woman experiencing prolonged labor?
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What can be a consequence of precipitate birth?
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Which type of pelvis is most favorable for vaginal births?
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Which of the following is a common response to excessive stress during labor?
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What is a characteristic of hypertonic labor?
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Which nursing care strategy is appropriate for a woman experiencing hypotonic labor?
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What is a common challenge in ineffective maternal pushing?
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Which condition may result in shoulder dystocia during labor?
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In which fetal presentation is a cesarean delivery most commonly performed in the US?
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What is a nursing care consideration for a woman experiencing abnormal fetal presentation?
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What is one way to manage a woman’s fatigue during labor?
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What is a key feature of persistent occiput posterior position in labor?
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Study Notes
Induction and Augmentation of Labor
- Induction of labor is the artificial initiation of labor before spontaneous labor has begun.
- Augmentation of labor is the stimulation of labor that has already begun.
- Indications for Labor Induction: Gestational hypertension, premature rupture of membranes (PROM), infection within the uterus (chorioamnionitis), Diabetes, renal disease, pulmonary disease, fetal growth restriction, prolonged pregnancy, fetal-maternal blood incompatibility, placental insufficiency, fetal death.
- Contraindications for Labor Induction: Placenta previa, umbilical cord prolapse, abnormal fetal presentation, high fetal station, active herpes infection, abnormal maternal pelvis, previous classical cesarean birth.
Nonpharmacologic Methods to Stimulate Contractions
- Walking stimulates contractions and eases pressure on the mother's back.
- Sitting, squatting, and kneeling in an upright position can also help.
- Nipple stimulation releases oxytocin, improving the quality of contractions.
Pharmacological and Mechanical Methods to Stimulate Contractions
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Cervical Ripening: The physical softening of the cervix that leads to effacement and dilation.
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Pharmacologic Methods:
- Prostaglandin E2 (Dinoprostone) via vaginal insert.
- Prostaglandin E1 (Misoprostol) orally or intravaginally.
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Mechanical Methods:
- Stripping the amniotic membranes.
- Hydroscopic dilators (Laminiaria & Lamicel).
- Transcervical balloon dilators.
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Pharmacologic Methods:
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Amniotomy: Artificial rupture of membranes (AROM) using a sterile instrument to puncture the amniotic sac.
- Risks: Umbilical cord prolapse, infection, abruptio placentae.
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Oxytocin Induction and Augmentation of Labor:
- Pitocin (oxytocin) is commonly used for labor induction and augmentation.
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Complications of augmentation:
- Tachysystole (hypertonic uterine activity), uterine rupture, maternal water intoxication.
Amnioinfusion
- Injection of warmed saline or lactated Ringer's solution into the uterus during labor after ruptured membranes.
- Indications: Oligohydramnios, umbilical cord compression, reducing variable decelerations, diluting meconium-stained amniotic fluid.
Version
- Changing the fetal presentation, usually from breech or oblique to cephalic.
- External Version: Performed after 37 weeks before labor onset using ultrasound and tocolytics.
- Internal Version: An emergency procedure performed during a vaginal birth of twins.
Episiotomy and Lacerations
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Episiotomy: Surgical enlargement of the vaginal opening during birth.
- Indications: Better control over the vaginal opening, provides a clean edge for healing.
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Laceration: An uncontrolled tear of the vaginal tissues.
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Degrees of Laceration:
- First degree: superficial vaginal mucosa or perineal skin.
- Second degree: vaginal mucosa, perineal skin, and deeper tissues.
- Third degree: Second degree plus involvement of the anal sphincter.
- Fourth degree: Extends through the anal sphincter into the rectal mucosa.
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Degrees of Laceration:
Forceps and Vacuum Extraction Births
- Used to provide traction and rotation of the fetal head when the mother's pushing efforts are insufficient.
- Forceps: Curved blades that fit around the fetal head, used in cephalic or breech deliveries.
- Vacuum Extractor: Suction applied to the fetal head, used only with an occiput presentation.
- Indications: Maternal exhaustion, cardiac or pulmonary disorders, fetal distress near the end of labor.
- Contraindications: Maternal or fetal conditions requiring a quicker delivery, situations where a cesarean birth would be less traumatic.
- Risks: Maternal vaginal lacerations or hematomas, fetal facial bruising, scalp lacerations, cephalhematoma, intracranial hemorrhage, chignon (harmless scalp edema).
Cesarean Birth
- Surgical delivery of the fetus through incisions in the abdomen and uterus.
- Indications: Abnormal labor, cephalopelvic disproportion, maternal conditions (gestational hypertension, diabetes), active maternal herpes infection.
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Goals for Reducing Cesareans:
- Position variation (squatting), epidural/subarachnoid analgesia for ambulation, oxytocin augmentation, spontaneous open glottis pushing, vacuum assisted delivery, electronic fetal and uterine monitoring.
Cesarean Birth
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Indications:
- Previous surgery on the uterus.
- Fetal compromise, including prolapsed umbilical cord and abnormal presentations.
- Placenta previa or abruptio placentae.
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Contraindications:
- Not usually performed if the fetus is dead or too immature to survive.
- Not performed if the mother has abnormal blood clotting.
- Should not be planned for the convenience of the woman.
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Risks:
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Maternal:
- Risks related to anesthesia.
- Respiratory complications.
- Hemorrhage.
- Blood clots.
- Injury to the urinary tract.
- Delayed intestinal peristalsis.
- Infections.
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Newborn:
- Inadvertent preterm birth, usually prevented by an amniocentesis before a planned cesarean birth.
- Respiratory problems.
- Injury, such as laceration or bruising.
- Scarring of the uterus that may influence progress of future pregnancies.
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Maternal:
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Techniques:
- Preparation includes routine preoperative care:
- Obtaining informed consent.
- Labs for CBC, coagulation studies, and blood typing.
- History screening.
- Baseline vital signs of mother and fetal heart rate.
- Preoperative teaching.
- Placement in a supine position with a wedge under the hip.
- Regional anesthesia is administered and medication to decrease gastric acidity.
- Prophylactic IV antibiotic may be administered before surgery.
- Indwelling Foley catheter is inserted.
- Circulating nurse scrubs the abdomen with chlorhexidine.
- Women who have cesarean births usually need greater emotional support.
- The partner may be frightened so supporting them is essential.
- Preparation includes routine preoperative care:
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Types of Incisions:
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Skin Incision:
- Can be vertical or transverse.
- Vertical allows for more room for a large fetus.
- Transverse is nearly invisible but not always used in obese women or with large fetuses.
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Uterine Incisions:
- Low transverse: Preferred because it is not likely to rupture during another birth.
- Low vertical: Produces minimal blood loss but is more likely to rupture during another birth.
- Classic incision: Rarely used because it involves more blood loss and is the most likely to rupture during another pregnancy.
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Skin Incision:
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Nursing Care:
- Mother, neonate, and partner are kept together as much as possible.
- Assessments are similar to after vaginal birth, including the fundus.
- Vital signs are monitored to identify hemorrhage or shock.
- IV site and rate of IV solution are monitored.
- Fundus is checked for firmness, height, and presence of clots.
- Deep breathing, turning, and coughing with splinting should be done with each assessment.
- Change position every 1-2 hours.
- Pain management may be accomplished by PCA or intermittent injections of narcotic analgesics.
Dysfunctional Labor
- Abnormalities in the powers, passengers, passage, or psyche may result in dysfunctional labor.
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Problems with Powers of Labor:
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Hypertonic Labor:
- Usually occurs in the latent phase before 4 cm of cervical dilatation.
- Characterized by frequent, painful, and poorly coordinated contractions.
- Uterine resting tone between contractions is tense.
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Nursing Care:
- Accept the woman’s and partner’s frustration.
- Offer warm showers or baths to promote relaxation.
- Do not equate the amount of pain a woman reports with how much she “should” feel.
- Provide general comfort measures.
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Hypotonic Labor:
- Occurs during the active phase, after 4 cm of cervical dilatation.
- Contractions are weak, diminished, and ineffective.
- Uterine resting tone is not elevated.
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Nursing Care:
- Allow the woman to express her frustrations.
- Provide care related to amniotomy or augmentation.
- Position changes may help to relieve discomfort.
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Ineffective Maternal Pushing:
- May result from:
- Woman may not understand which techniques to use.
- Fears of tearing her perineal tissues.
- Epidural and subarachnoid blocks may depress or eliminate the natural urge to push.
- An exhausted woman may be unable to gather her resources to push appropriately.
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Nursing Care:
- Focus on coaching the woman about effective pushing techniques.
- Tell her when to push if she cannot feel her contractions.
- Exhausted women may benefit from pushing only when they feel a strong urge.
- May result from:
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Hypertonic Labor:
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Problems with Passenger:
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Fetal Size:
- Macrosomia: A fetus weighing more than 4000 g (8.8 lbs.) at birth.
- Shoulder dystocia: Occurs when the fetus is large and the shoulders become impacted above the mother’s symphysis pubis.
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Nursing Care:
- Apply firm downward pressure just above the symphysis pubis.
- Observe the mother and fetus for injuries.
- The woman is more at risk for uterine atony and postpartum hemorrhage.
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Abnormal Fetal Presentation or Position:
- Breech presentation: Most fetuses in the breech presentation are born by cesarean delivery.
- Abnormal rotation position: Persistent occiput posterior position is a common cause of abnormal labor.
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Nursing Care:
- Encourage positions that favor fetal rotation and decent.
- Observe the mother and fetus for signs of birth trauma.
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Multifetal Pregnancy:
- Several factors can make dysfunctional labor likely:
- Uterine overdistention contributes to poor contraction quality.
- Abnormal presentation or position of one or more of the fetuses interferes with labor mechanisms.
- Often one fetus is delivered as cephalic and the second as breech.
- Several factors can make dysfunctional labor likely:
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Fetal Size:
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Problems with the Passage:
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Bony Pelvis:
- Some women have a small or abnormally shaped pelvis that impedes the normal mechanisms of labor.
- Gynecoid pelvis is the most favorable for vaginal births.
- A trial labor is the ultimate test of the woman’s pelvis size.
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Soft Tissue Obstructions:
- The most common soft tissue obstruction during labor is a full bladder.
- Encourage the woman to urinate every 1-2 hours.
- Catheterization may be needed.
- Less common soft tissue obstructions include:
- Pelvic tumors.
- Cervical scarring.
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Bony Pelvis:
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Problems with Psyche:
- Excessive or prolonged stress can increase stress and cause dystocia.
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Nursing Care:
- Promoting relaxation and helping the woman conserve her resources for the work of childbirth are the principal goals.
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Abnormal Duration of Labor:
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Prolonged Labor:
- Results from problems with any of the factors in the laboring process.
- Average cervical dilation during the active phase of labor is about 1.2 cm/hr for the woman having her first child and about 1.5 cm/hr in a woman who has had a child before.
- Descent is expected to occur at a rate of at least 1 cm/hr in a first-time mother and 2 cm/hr in a woman who has had a child before.
- Friedman curve is often used to graph the progress of cervical dilation and fetal descent.
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Nursing Care:
- Focuses on helping the woman conserve her strength.
- Encouraging her as she copes with the long labor.
- Observe for infection.
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Precipitate Birth:
- Birth is completed in less than 3 hours, and there may be no healthcare provider present.
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Maternal Response:
- Labor often begins abruptly and intensifies quickly.
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Fetal Response:
- Oxygenation can be compromised by intense contractions.
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Nursing Care:
- Require support and reassurance concerning the deviation from the expected experience.
- Observe mother and infant for signs of injury.
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Prolonged Labor:
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Premature Rupture of Membranes:
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Definitions:
- PROM (premature rupture of membranes): Spontaneous rupture of the membranes at term more than 1 hour before labor contractions begin.
- PPROM (preterm, premature rupture of membranes): Rupture of membranes before term, with or without contractions.
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Diagnosis:
- Nitrazine paper turns blue in the presence of amniotic fluid.
- Fern Test: shows a ferning pattern of amniotic fluid on a slide under the microscope.
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Treatment:
- Based on weighing the risks of early delivery against the risks of infection.
- If PROM occurs at 36 weeks of gestation or later, labor is induced within 24 hours.
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Definitions:
Umbilical Cord Prolapse
- Occurs when the umbilical cord slips downward after the membranes rupture, subjecting it to compression between the fetus and pelvis.
- Interruption in blood flow through the cord interferes with fetal oxygenation and is potentially fatal.
- Complete prolapse: the cord can be seen protruding from the vagina.
- Palpated prolapse: the cord cannot be seen but it can be felt as a pulsating mass during vaginal exam.
- Occult prolapse: the cord is hidden and cannot be seen or felt during vaginal exam; it is suspected based on abnormal fetal heart rates.
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Risk factors:
- Fetus is high in the pelvis when the membranes rupture (presenting part is not engaged).
- Very small fetus, as in prematurity.
- Abnormal presentation: most likely footling breech or transverse lie.
- Hydramnios (large amount of fluid exerts more pressure).
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Medical Treatment:
- The physician may push the fetus upward from the vagina.
- Oxygen and a tocolytic drug such as terbutaline may be administered.
- The primary focus is to deliver the fetus by quickest means possible, usually cesarean delivery.
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Nursing Care:
- Immediately displace the fetus upward to stop compression against the pelvis, via positioning.
- Position woman’s hips higher than her head to shift the fetal presenting part toward her diaphragm:
- Knee-chest position.
- Trendelenburg.
- Hips elevate with pillows, with side-lying maintained.
- Assist with emergency procedures and prepare for surgery.
- Calm, quick actions to reduce anxiety in woman and family.
- After birth, help the woman understand the experience.
Uterine Rupture
- A tear in the uterine wall that occurs if the uterine muscle cannot withstand the pressure against it.
- Complete Rupture: There is a hole through the uterine wall, from the uterine cavity to the abdominal cavity.
- Incomplete Rupture: The uterus tears into a nearby structure, such as a ligament, but not all the way into the abdomen.
- Dehiscence: An old uterine scar, usually from a previous cesarean birth, separates.
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Risk Factors:
- Previous uterine surgery, especially C-section with classical incision.
- Intense contractions (tachysystole) as a result of induction of labor with oxytocin.
- Blunt abdominal trauma such as from a motor vehicle accident or from battering.
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Characteristics:
- May have no symptoms or sudden severe symptoms.
- Shock due bleeding into the abdomen (vaginal bleeding may be minimal).
- Abdominal pain and tenderness.
- Chest pain, pain between the scapulae, or with inspiration.
- Cessation of contractions.
- Abnormal FHR tracing from impaired fetal oxygenation or absent fetal heart rates.
- Palpation of the fetus outside the uterus, (usually with large, complete rupture).
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Medical treatment:
- Perform surgery to deliver the fetus and stop the bleeding.
- For small rupture, it may be repaired.
- A large rupture requires hysterectomy and blood products.
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Nursing Care:
- Be aware of women who are at high risk for uterine rupture and close monitoring during labor is essential.
- Prepare for immediate cesarean section.
- Alleviate anxiety in the woman and her partner.
- Uterine rupture may not be detected before birth. She may have continuous bleeding that is brighter red than the normal post birth bleeding, rising pulse rate and falling blood pressure, indicating hypovolemic shock.
Anaphylactoid Syndrome (Amniotic Fluid Embolism)
- Occurs when amniotic fluid, with its particles such as vernix, fetal hair, and sometimes meconium, is drawn into the maternal circulation and obstructs pulmonary vessels.
- It is likely to occur during a very strong labor because the fluid is “pushed” into small blood vessels that rupture as the cervix dilates.
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Characteristics:
- Hypotension.
- Respiratory distress.
- Coagulation abnormalities triggered by the thromboplastin contained in the amniotic fluid.
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Treatment:
- Respiratory support with intubation and mechanical ventilation as necessary.
- Correction of hypotension with volume expanders, electrolytes and packed red blood cells.
- Correct coagulation factors, such as platelets and fibrinogen.
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Nursing Care:
- Monitor intake and output closely.
- Monitor oxygen saturation.
- Closely monitored in the intensive care unit.
Nursing Considerations for a Pregnant Woman Following a Vehicle Accident
- Priority fetal assessment: For poor oxygenation due to maternal blood loss which reduces available blood (and therefore oxygen) to the fetus.
Nursing Considerations for Prolapsed Umbilical Cord
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Situations to be especially watchful for prolapsed cord:
- Fetus high in the pelvis when the membranes rupture.
- Very small fetus.
- Abnormal fetal presentation.
- Polyhydramnios.
Uterine Rupture Variations
- Complete: there is a hole through the full thickness of the uterine wall into the abdominal cavity.
- Incomplete: uterus tears into a nearby structure, such as a ligament.
- Dehiscence: separation of an old uterine scar, often without bleeding.
Back Pain During Labor
- Persistent back pain that worsens during contractions may indicate the baby is in a posterior position.
- Nurses should encourage frequent position changes to alleviate pain and promote fetal rotation.
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Positions that help:
- Leaning forward while sitting, kneeling, or standing.
- Hands-and-knees position.
- Lunging towards the right side.
- Left side-lying position in bed.
Bishop Score
- Assesses cervical readiness for induction of labor.
- A score of 6 or more indicates a favorable prognosis for induction.
- Factors considered:
- Cervical dilation.
- Effacement.
- Consistency and length of cervix.
- Position of cervix.
- Station of presenting part.
Induction vs. Augmentation of Labor
- Induction: Deliberate initiation of labor before it begins naturally.
- Augmentation: Stimulation of contractions after they have begun naturally.
Contraindications for Induction/Augmentation
- High fetal station.
- Placenta previa or cord around the neck.
- Abnormal maternal pelvic size or structure.
- Previous classic surgical uterine incision.
- Active maternal herpes infection.
Non-Pharmacological Labor Stimulation
- Nurse can assist with comfortable upright positions.
- Breast nipple stimulation by hand or shower stream.
- Partner can encourage walking, distraction, and support.
Nursing Responsibilities During Oxytocin Administration
- Reinforce plans and process with the woman.
- Monitor fetal heart rate and maternal vital signs.
- Monitor contraction strength and frequency.
- Report contractions lasting longer than 90 seconds or occurring more frequently than 5 in 10 minutes.
- Maintain accurate intake and output records.
- Prepare emergency measures.
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Description
Test your knowledge on nursing care practices during labor and delivery. This quiz covers various procedures, medications, and nursing interventions essential for ensuring a safe childbirth experience. Challenge yourself with questions regarding amnioinfusion, labor induction, and other critical aspects of obstetrical care.
