Obstetrics: Cervical Insufficiency and Placenta Previa

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Questions and Answers

What is a common characteristic of placental abruption?

Painful, dark-red vaginal bleeding (correct)

Painless abdominal swelling

Increased fetal movement

Clear vaginal discharge

What classification of placental abruption involves severe bleeding greater than 1,500 mL?

Critical (grade 4)

Mild (grade 1)

Severe (grade 3) (correct)

Moderate (grade 2)

Which action is essential for monitoring a patient suspected of placental abruption?

Measure blood pressure only once per shift

Check fetal heart rate and uterine contractions frequently (correct)

Limit maternal movement completely

Administer pain medication without assessment

What is a significant maternal risk associated with placental abruption?

Renal failure Signup and view all the answers

What should be readily available for a patient experiencing placental abruption and showing signs of maternal or fetal distress?

IV site for fluid administration Signup and view all the answers

What typically characterizes cervical insufficiency during pregnancy?

Quick dilation of the cervix without noticeable contractions Signup and view all the answers

Which option is a common management strategy for cervical insufficiency?

Cervical cerclage placement Signup and view all the answers

What is a possible complication associated with cervical cerclage?

Suture displacement Signup and view all the answers

What is a known risk factor for placenta previa?

Advanced maternal age Signup and view all the answers

How does placenta previa commonly present during pregnancy?

Bright-red vaginal bleeding without pain Signup and view all the answers

Which statement about the incidence of placenta previa is true?

Risk increases with each cesarean section Signup and view all the answers

What should be avoided in the nursing management of placental previa?

Performing vaginal examinations Signup and view all the answers

What is the estimated incidence of cervical insufficiency in the obstetrical population?

Less than 1% Signup and view all the answers

What is the primary nursing intervention for a patient experiencing abruption?

Administer oxygen and maintain strict bed rest in left lateral position Signup and view all the answers

What is a common complication associated with placental abnormalities?

Hysterectomy due to severe hemorrhage Signup and view all the answers

Which of the following conditions is characterized by excessive amniotic fluid?

Polyhydramnios Signup and view all the answers

What is a nursing management strategy for oligohaemnios?

Continuous fetal heart rate monitoring Signup and view all the answers

How is a diagnosis of premature rupture of membranes (PROM) commonly confirmed?

Speculum vaginal exam revealing pooling of fluid Signup and view all the answers

What is a potential risk of preterm premature rupture of membranes (PPROM)?

Infection and perinatal compromise Signup and view all the answers

Which symptom might indicate a complication in a patient with polyhydramnios?

Increased fundal height and dyspnea Signup and view all the answers

What is a key finding in the assessment of oligohydramnios?

Decreased amniotic fluid levels confirmed by ultrasound Signup and view all the answers

What nursing action is essential for managing multiple gestation during labor?

Continuous fetal heart rate monitoring Signup and view all the answers

What condition refers to the obstruction of fetal descent during birth?

Shoulder dystocia Signup and view all the answers

Which medication may decrease fetal urinary output in cases of polyhydramnios?

Indomethacin Signup and view all the answers

What is a significant maternal risk factor during the assessment of PROM?

Recent urinary tract infection Signup and view all the answers

Which diagnostic method is used to assess pockets of amniotic fluid in polyhydramnios?

Ultrasound Signup and view all the answers

What is an expected consequence of severe oligohydramnios for the fetus?

Heightened risk of cord compression Signup and view all the answers

What is the recommended action when shoulder dystocia occurs during childbirth?

Apply the McRoberts maneuver and suprapubic pressure Signup and view all the answers

What condition is characterized by maternal risks such as postpartum hemorrhage and uterine rupture?

Shoulder dystocia Signup and view all the answers

What would decrease the likelihood of preterm labor occurring?

Waiting 18 months between pregnancies Signup and view all the answers

What effect do corticosteroids have when administered to mothers in preterm labor?

Improve fetal lung maturity Signup and view all the answers

What key marker is used to predict imminent spontaneous rupture of membranes (SROM) within 7-14 days?

Fetal fibronectin test Signup and view all the answers

Which of the following is a primary risk factor for developing amniotic fluid embolism (AFE)?

Presence of meconium in amniotic fluid Signup and view all the answers

Which statement regarding tocolytic therapy is true?

Magnesium sulfate is a commonly used tocolytic drug Signup and view all the answers

What is defined as any pregnancy that extends beyond 42 weeks gestation?

Post-term pregnancy Signup and view all the answers

What is the primary concern in cases of umbilical cord prolapse?

Fetal cord compression Signup and view all the answers

Which of the following best describes the management of preterm labor?

Use of tocolytics and supportive therapies Signup and view all the answers

What is the best way to manage a patient suspected of experiencing an amniotic fluid embolism?

Supportive care and stabilization Signup and view all the answers

Which complication is NOT associated with macrosomia?

Low blood pressure in the neonate Signup and view all the answers

What maternal condition typically contraindicates the use of tocolytic therapy?

Active vaginal bleeding Signup and view all the answers

Study Notes

Cervical Insufficiency

Describes a weak cervix that dilates without contractions
Occurs in the second or early third trimester
Results in loss of pregnancy
< 1% incidence in obstetrical population
Dilation is usually rapid, painless, and produces minimal bleeding

Management of Cervical Insufficiency

Bed rest
Pelvic rest
No lifting heavy objects
Progesterone supplementation
Cervical pessary
Cervical cerclage procedure in the second trimester

Cervical Cerclage

Performed transvaginally or transabdominally
Heavy purse string suture reinforces the internal os of the cervix
May be placed up to 28 weeks
Complications include suture displacement, rupture of membranes, and infection

Placenta Previa

Placenta implants over the cervical os
Occurs during the last two trimesters
Odds in first pregnancy are 1/400 but increase with each cesarean section
Consequences include hemorrhage, abruption, and emergency C-section
Exact cause unknown but may be due to scarring or damage to the upper uterine segment

Nursing Assessment of Placenta Previa

Assess for risk factors: advanced maternal age, previous C-section, multiparty, uterine insult or injury, prior previa, multiple gestations, previous surgical abortion, short interval between pregnancies
Presents as painless, bright-red vaginal bleeding in the second or third trimester
Initial bleeding usually occurs between 27-32 weeks gestation, is not profuse, and ceases spontaneously

Placenta Previa: Nursing Management

No vaginal exams!
Assess vaginal bleeding (peripad count or weighing pads)
Monitor maternal VS, pain, FHR, and UCs frequently
Oxygen equipment should be readily available
Must have an IV site
Prolonged hospitalization or home bed rest may be necessary
Educate client and family about signs and symptoms
Prepare client for the possibility of C-section
Encourage client to notify provider if any change in condition

Placental Abruption

Premature separation of a normally implanted placenta
Leads to hemorrhage
Painful, dark-red vaginal bleeding, severe abdominal pain, uterine tenderness, contractions, and decreased fetal movement
Maternal risks: hemorrhage, blood transfusions, emergency hysterectomy, DIC, renal failure, death
Fetal risks: low birth weight, preterm delivery, asphyxia, stillbirth, death
Occurs when bleeding from a blood vessel creates a clot between the placenta and uterine wall
Continued bleeding causes increased pressure behind the placenta, resulting in separation from the uterine wall.
Fetal distress is proportional to the degree of placental separation

Classifications of Abruption

Classified by extent of separation and amount of blood loss
- Mild (grade 1): minimal bleeding (< 500 mL)
- Moderate (grade 2): moderate bleeding (100-1,500 mL)
- Severe (grade 3): severe bleeding (> 1,500 mL)
May also be classified as partial or complete, depending on the degree of separation
Concealed/internal bleeding versus Revealed/external bleeding

Abruption: Nursing Management

Strict bed rest in left lateral position
Administer oxygen
Monitor maternal VS every 15 minutes
Continuous fetal monitoring
Two large bore IV sites
Assess UCs
Assess abdominal girth/fundal height
Watch for signs and symptoms of DIC: bleeding gums, tachycardia, oozing from IV site
Provide emotional support

Placental Abnormalities

Cause unknown but may be related to placenta previa, advanced maternal age, smoking, and previous C-sections
90% will have postpartum hemorrhage
50% will have a hysterectomy
Typically diagnosed after birth when the placenta fails to separate from the uterine wall
Profuse hemorrhage may occur as the uterus cannot contract to close off open blood vessels
Hysterectomy is often necessary, depending on the severity of bleeding

Polyhydramnios (Hydramnios)

Too much amniotic fluid (>2000 mL) between 32-36 weeks gestation
Associated with maternal disease (diabetes) and fetal anomalies
Increased incidence of preterm births, fetal malpresentation, and cord prolapse
Mild to moderate: close monitoring, frequent follow-up visits
Severe: amniocentesis or artificial rupture of membranes (AROM)
Indomethacin may be given to decrease fetal urinary output

Nursing Assessment and Management of Polyhydramnios

Measure fundal height
UCs due to overstretching of the uterus
Dyspnea due to pressure on the diaphragm
Edema in lower extremities due to pressure on the vena cava
Diagnosis: ultrasound to measure pockets of amniotic fluid for total volume
Educate client about preterm labor and preterm rupture of membranes

Oligohydramnios

Decreased amount of amniotic fluid (< 500 mL) at 32-36 weeks, or 42 weeks, natural decline occurs
Reduces the fetus's ability to move freely, increasing the risk of cord compression, fetal death, and intrapartal hypoxia
Typically identified on ultrasound

Management of Oligohydramnios

Serial ultrasounds, non-stress tests, and biophysical profiles (BPPs)
If fetal well-being is compromised, birth is planned with amnioinfusion
Amnioinfusion improves abnormal FHR patterns and decreases C-sections
Risk factors: uteroplacental insufficiency, premature rupture of membranes, hypertension, maternal diabetes, intrauterine growth restriction, post-term pregnancy, fetal renal abnormalities
Continuously monitor FHR
Variable decelerations, indicating cord compression, are commonly seen
Carefully monitor amnioinfusion to prevent overdistention of the uterus

Management of Multiple Gestation

Serial ultrasounds to assess fetal growth and development
BPPs, non-stress tests, possible hospitalization in late pregnancy to prevent preterm labor and closer monitoring
C-section is often necessary due to fetal malpresentation
Be alert for fatigue, severe nausea/vomiting, and a larger than expected uterus
Educate client on signs and symptoms of preterm labor and to report immediately
During labor monitor FHRs continuously
Postpartum closely monitor the woman for hemorrhage secondary to uterine atony

Premature Rupture of Membranes (PROM)

Rupture of the bag of waters before onset of true labor
Occurs in a woman > 37 weeks gestation who is not in labor
Complications include infection, prolapsed cord, and abruption
Woman presents with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure but is not having contractions
Diagnosed via speculum vaginal exam: pooling of fluid, ferning, nitrazine

Preterm Premature Rupture of Membranes (PPROM)

Rupture of membranes before the onset of labor in a woman < 37 weeks
Perinatal risks stem from immaturity: respiratory distress syndrome, intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis
Unknown etiology but may be associated with vaginal bleeding, abruption, infection, defective placentation
Increased risk with previous history of PPROM or a short interval between pregnancies

Treatment of PROM & PPROM

Depends on gestational age
If fetal lungs are mature: induction of labor
If fetal lungs are immature: hydration, activity restrictions, pelvic rest, close observation for infection, betamethasone, antibiotics
Nursing assessment focuses on obtaining a complete health history and performing a physical exam to determine maternal and fetal status

Nursing Management of PROM & PPROM

Determine the date, time, and duration of SROM
Rule out recent UTIs or vaginal infections
Administer antibiotics
Monitor VS
Serial WBC measurements
Determine gestational age
Assess continually for signs of labor
Report fetal tachycardia (maternal infection) or variable decelerations (cord compression)
Typically admitted until delivery

Shoulder Dystocia

The obstruction of fetal descent and birth by the axis of fetal shoulders after the fetal head is delivered
Emergency! Increasing incidence due to increasing birth weights
No predictor for shoulder dystocia
Maternal risks: postpartum hemorrhage, vaginal lacerations, anal tears, uterine rupture
Fetal risks: transient brachial plexus palsy, clavicle or humerus fractures, cord compression
McRoberts maneuver or suprapubic pressure can reduce the severity of injuries

Management of Shoulder Dystocia

McRoberts Maneuver: newborn's head depressed toward the mother’s anus while pressure is applied
Suprapubic pressure: light pressure applied just above the pubic bone, pushing the fetal anterior shoulder downward

Macrosomia

Newborn weighs > 4,500 g (9.9 lb.) at birth
Risks: maternal diabetes, obesity
Complications: increased risk of postpartum hemorrhage, shoulder dystocia, low Apgar scores, dysfunctional labor, fetopelvic disproportion, vaginal lacerations, fetal injuries or fractures, perinatal asphyxia
Scheduled C-section often done with primigravida
Vacuum and forceps-assisted births are common

Preterm Labor

Occurrence of regular contractions, cervical dilation and effacement before 37 weeks
Contractions must be persistent, effacement >80%, dilation > 1 cm
Prevention is the goal
Management of preterm labor: tocolytic drugs, antibiotics, steroids

Tocolytic Therapy

Most likely ordered if preterm labor occurs before the 34th week
Does not prevent birth, but can delay it
A serious side effect is maternal pulmonary edema
Contraindicated for abruptions, fetal distress or death, fetus before viability, severe preeclampsia, PPROM, active vaginal bleeding, dilatation > 6 cm, chorioamnionitis, maternal hemodynamic instability

Tocolytic Drugs

Magnesium sulfate
Indomethacin (Indocin)
Nifedipine (Procardia)
Terbutaline sulfate (Brethine)

Corticosteroids

Betamethasone (Celestone)
Given to mothers in preterm labor to help prevent or reduce the severity of respiratory distress syndrome in premature infants
Promotes fetal lung maturity by stimulating surfactant production
Administer two doses IM, 24 hours apart
Beneficial effects reported within 48 hours of the initial dose
Repeat doses are supported if the patient is still at risk for preterm birth 7 days or more after the initial course

Labs and Diagnostic Testing: Preterm Labor

Fetal fibronectin: useful marker for impending SROM within 7-14 days
Cervical length measurement: > 3 cm indicates delivery within 14 days is unlikely

Preterm Birth Education

Risk factors: multiple gestation, prior preterm birth, low socioeconomic status, maternal medical disorders, and maternal infections
Avoid lifting heavy objects, wait at least 18 months between pregnancies, avoid use of substances, no sexual activity
Signs and symptoms of preterm labor: drink water, lie down on your side and rest for 1 hour, palpate your abdomen for the strength of UCs, call your HCP

Post-term Pregnancy

Any pregnancy > 42 weeks gestation
Maternal risks: C-section, shoulder dystocia, birth trauma, postpartum hemorrhage, infection
Fetal risks: macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, cephalopelvic disproportion
Uteroplacental insufficiency, meconium aspiration, intrauterine infection contribute to perinatal death
As the placenta ages, perfusion decreases
Amniotic fluid begins to decline after 38 weeks
Fetal hypoxia and an increased risk of cord compression predispose the fetus to meconium aspiration

Nursing Management of Post-term Pregnancy

Accurate gestational age via ultrasound
Induction can be deferred until 42 weeks if reassuring FHR pattern
Daily fetal movement counts
Non-stress tests with amniotic fluid assessments
Priority: monitoring fetal well-being

Umbilical Cord Prolapse

Rare OB emergency involving the protrusion of the umbilical cord alongside or ahead of the presenting part of a fetus
Usually leads to total or partial occlusion of the cord
Perfusion deteriorates rapidly, and the fetus will die if cord compression is not relieved
Risk factors: malpresentation, fetal growth restriction, prematurity, rupture of membranes with fetus at high station, polyhydramnios, grandmultiparity, and multiple gestation

Nursing Management of Cord Prolapse

First sign of cord prolapse: sudden fetal bradycardia or recurrent variable decelerations
Call for help immediately
Assist with measures to relieve compression: place a sterile gloved hand into the vagina and hold the presenting part off the umbilical cord
Change position to left lateral, Trendelenburg, or knee-chest
Monitor FHR, maintain bed rest, and administer oxygen
Emergency C-section

Amniotic Fluid Embolism (AFE)

Amniotic fluid containing debris (hair, skin, vernix, or meconium) enters maternal circulation and obstructs pulmonary vessels, causing sudden respiratory distress and circulatory collapse
Pathophysiology involves an abnormal maternal response to fetal tissue exposure associated with breaches of the maternal-fetal physiologic barrier
Normally amniotic fluid does not enter maternal circulation because it is contained within the uterus, sealed off by the amniotic sac
Embolus occurs when the barrier between the maternal circulation and amniotic fluid is broken
50% die within the first hour of onset of symptoms, 85% of survivors have permanent neurological damage

Nursing Care: AFE

Immediate recognition and diagnosis are key: acute onset of dyspnea, chest pain, frothy sputum, hypotension, tachycardia, and massive hemorrhage
Supportive care: maintain oxygenation, hemodynamic function, and correct coagulopathy
Resuscitation, intubation, mechanical ventilation
Vasopressors used to maintain hemodynamic status
Management of DIC involves replacement with packed red blood cells and fresh-frozen plasma
Oxytocin infusions to address uterine atony
Transfer to ICU

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Description

This quiz covers key concepts related to cervical insufficiency and placenta previa, including definitions, management strategies, and potential complications. Understand the significance of both conditions in pregnancy and their implications for maternal and fetal health.