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48 Cards in this Set
- Front
- Back
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Labor induction - is the chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about the birth.
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-indications: medical and obstetric reasons include gestational hypertension, diabetes mellitus, chorioamnionitis, and other maternal medical problems; PROM; postdate gestation; suspected fetal jeopardy (e.g., IUGR); logistic factors, such as history of previous rapid birth or distance of the woman's home from the hospital; and fetal death.
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Labor induction
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success rates for induction of labor are higher when the cervix is favorable, or inducible. A rating system such as the Bishop score can be used to evaluate inducibility. For example, a score of 9 or more on this 13-point scale indicates that the cervix is soft, anterior, 50% or more effaced, and dilated 2 cm or more; and that the presenting part is engaged.
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Bishop score
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Induction of labor is likely to be more successful if the score is 8 or more.
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Labor induction: procedures
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Cervical ripening methods: chemical agents -- A prostaglandin gel was approved by the FDA in 1993 as a cervical ripening agent. Preparations of Prostaglandin E1 and prostaglandin E2 can be used before induction to "ripen" (soften and thin) the cervix. This treatment usually results in a higher success rate for the induction of labor, the need for lower dosages of oxytocin during the induction, and shorter induction times. In some cases, women will go into labor after the application of prostaglandin, thereby eliminating the need to administer oxytocin to induce labor.
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Medication Moment: Prostaglandins
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-Pg gel
-prepidil -Cervadil -Cytotec prostaglandins ripen (soften and thin) the cervix. |
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Prostaglandin E1
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although less expensive and more effective than oxytocin or prostaglandin E2 for inducing labor and birth, is associated with a higher risk for hyperstimulation of the uterus and nonreassuring changes in fetal heart rate and pattern.
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Prostaglandin: Cervidil
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Cervidil tape (extremely expensive) inserted vaginally up behind the cervix. S/E overstimulation of the uterus, hyperstimulation of the uterus
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Medication Moment: Pitocin
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The indications for oxytocin induction of labor may include, but are not limited to, the following:
suspected fetal jeopardy (IUGR) inadequate uterine contractions; dystocia premature rupture of membranes postterm pregnancy chorioamnionitis--inflammation of the amnion, usually secondary to bacterial infection. This condition is an obstetric emergency that may cause conditions such as pneumonia, meningitis, or sepsis in the neonate, and bacteremia or sepsis in the mother. Maternal medical problems Gestational hypertension (e.g., eclampsia) fetal death multiparous women with a history of precipitous labor who live far from the hospital. |
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Medication Moment: Pitocin
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Augmentation: a labor that is progressing slowly because of inadequate uterine contractions
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Medication Moment: Pitocin
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Warnings: Oxytocin use can present hazards to the mother and the fetus. These hazards are primarily dose related, with most problems caused by high doses that are given rapidly.
Maternal hazards: water intoxication and tumultuous labor with tetanic contractions, which may cause premature separation of the placenta, rupture of the uterus, lacerations of the cervix, or postbirth hemorrhage. These complications can lead to infection, disseminated intravascular coagulation, or amniotic fluid embolism. |
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Medication Moment: Pitocin
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Warnings: fetal hazards -- uterine hyperstimulation reduces the blood flow through the placenta and results in FHR decelerations (bradycardia, diminished variability, late decelerations), fetal asphyxia, and neonatal hypoxia. If the estimated date of birth is inaccurate, physical injury, neonatal hyperbilirubinemia, and prematurity are other hazards.
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Augmentation of labor
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Augmentation of labor is the stimulation of uterine contractions after labor has started spontaneously but progress is unsatisfactory.
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Forceps-Assisted Birth
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A forceps assisted birth is one in which an instrument with two curved blades is used to assist in the birth of the fetal head.
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Maternal Indications for a Forceps-Assisted Birth
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Maternal indications for a forceps-assisted birth include the need to shorten the second stage in dystocia (difficult labor), to compensate for the woman's deficient expulsive efforts (e.g., if she is tired or has been given spinal or epidural anesthesia), or to reverse a dangerous condition (e.g., cardiac decompensation).
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Fetal Indications for a Forceps-Assisted Birth
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Fetal indications include the birth of a fetus in distress, certain abnormal presentations, and arrest of rotation, as well as to deliver an aftercoming head in a breech presentation.
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Conditions for a successful forceps-assisted birth
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the woman's cervix must be fully dilated to avoid lacerations and hemorrhage. The bladder should be empty. The presenting part must be engaged, and a vertex presentation is desired. Membranes must be ruptured so that the position of the fetal head can be determined and the forceps can firmly grasp the head during birth.
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Vacuum-Assisted Birth
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Vacuum-assisted birth, or vacuum extraction, is a birth method involving the attachment of a vacuum cup to the fetal head, using negative pressure to assist in the birth of the head. Prerequisites for use include a vertex presentation, ruptured membranes, and the absence of CPD - cephalopelvic disproportion.
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CPD-cephalopelvic disproportion
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Disparity between the dimensions of the fetal head and those of the maternal pelvis. When the fetal head is larger than the pelvic diameters through which it must pass, or when the head is extended as in a face or brow presentation and cannot rotate to accommodate to the size and shape of the birth canal, fetal descent and delivery are not possible.
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Version
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Version is the turning of the fetus artificially from one presentation to another by the physician. Version may be done externally or internally.
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External cephalic version
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external cephalic version (ECV) is used to attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth. It may be attempted in a labor and birth setting after 37 weeks of gestation.
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Contraindications to ECV
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Contraindications to External Cephalic Version include uterine anomalies, previous cesarean birth, CPD, placenta previa, multifetal gestation, and oligohydramnios.
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nurse's role during an attempted ECV
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the nurse continuously monitors the FHR, especially for bradycardia; checks maternal vital signs; and assesses the woman's level of comfort because the procedure may cause discomfort. After the procedure is completed, the nurse continues to monitor maternal VS, uterine activity, FHR and pattern and assess for vaginal bleeding until the woman's condition is stable.
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Representative Diagnosis: Complications related to 4 P's (Passenger, powers, pelvis, psyche)
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dysfunctional labor: hypotonic/hypertonic uterus
precipitous labor Fetal problems: fetal malpresentation macrosomia shoulder dystocia fetal distress/IUFD Uterine/placental problems chorioamnionitis--Inflammation of the amnion, usually secondary to bacterial infection. This condition is an obstetric emergency that may cause conditions such as pneumonia, meningitis, or sepsis in the neonate, and bacteremia or sepsis in the mother. Cord prolapse--premature expulsion of a loop of umbilical cord into the cervical or vaginal canal during labor before engagement of the presenting part, a potentially life-threatening event that occurs in about 2 of 1000 births. The greatest danger is neonatal asphyxia and death. Uterine rupture--a rare condition in which the uterine muscles are torn apart by the stresses of unrelieved obstructed labor, the parting of an old cesarean delivery scar, or aggressive induction or augmentation of labor. Placental adherence Amniotic fluid embolism--The entry of amniotic fluid through a tear in the placental membranes into the maternal circulation. Symptoms: Chest pain, dyspnea, cyanosis, tachycardia, hemorrhage, hypotension, or shock are potential symptoms. Amniotic fluid embolism is frequently fatal. Preterm & Posterm labor |
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Dysfunctional Labor (Powers)
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hypertonic-lot of pain in uterus, under 4 cm dilated. hard contractions, pain is out of relationship to stage of labor. Failure to progress cannot be diagnosed in the latent stage of labor
TX: fluids, pain meds, rest hypotonic-prolonged latent phase, protracted active phase. 1 cm/hr is the normal rate of cervical dilation. "secondary arrest of dilatation" = c-section |
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Dysfunctional Labor (Powers)
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Uncoordinated labor
Precipitous labor |
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Fetal Problems (passenger)
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Malpresentation--OP, brow, face, shoulder, breech, compound
Cephalopelvic disproportion (CPD)--also called fetopelvic disproportion (FPD), is often related to excessive fetal size (i.e., 4000 g or more). When CPD is present, the fetus cannot fit through the maternal pelvis to be born vaginally. |
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Fetal Problems (passenger)
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Macrosomia--excessive fetal size, or macrosomia, is associated with maternal diabetes mellitus, obesity, multiparity, or the large size of one or both parents.
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Fetal Problems (passenger)
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Shoulder dystocia--dystocia of fetal origin may be caused by anomalies, excessive fetal size and malpresentation, malposition, or multifetal pregnancy. Complications associated with dystocia of fetal origin include neonatal asphyxia, fetal injuries or fractures, and maternal vaginal lacerations.
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Fetal Problems (passenger)
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fetal distress/IUFD--A nonspecific clinical diagnosis indicating pathology in the fetus. The distress, which may be due to lack of oxygen, is judged by fetal heart rate or biochemical changes in the amniotic fluid or fetal blood. NO HEARTBEAT, 1st intervention: check mother's pulse, call provider so they can do an ultrasound.
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Uterine/Placental problems (passage)
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chorioamnionitis--uterine infections, tender uterus. symptoms: temp, odor to amniotic fluid, uterine tenderness
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Uterine/Placental problems (passage)
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Cord prolapse--prolapse of the umbilical cord occurs when the cord lies below the presenting part of the fetus. Umbilical cord prolapse may be occult (hidden, not visible) at any time during labor whether or not membranes are ruptured. It is most common to see frank (visible) prolapse directly after ROM, when gravity washes the cord in front of the presenting part.
Care management: prompt recognition of a prolapsed cord is important because fetal hypoxia resulting from prolonged cord compression (i.e., occlusion of blood flow to and from the fetus for more than 5 minutes) usually results in CNS damage or death of the fetus. Pressure on the cord may be relieved by the examiner putting a sterile gloved hand into the vagina and holding the presenting part off of the umbilical cord. The woman is assisted into a position such as a modified Sims', Trendelenburg, or knee-chest position, in which gravity keeps the presenting part off the cord. |
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Uterine/Placental problems (passage)
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Placental adherence--placenta accreta: a placenta in which the cotyledons have invaded the uterine musculature, resulting in difficult or impossible separation of the placenta
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Amniotic Fluid Emboli (AFE)
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occurs when amniotic fluid containing particles of debris (e.g., vernix, hair, skin cells, or meconium) enters the maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse.
Signs Respiratory Distress: Restlessness, Dyspnea, cyanosis, pulmonary edema, respiratory arrest Signs circulatory collapse: hypotension, tachycardia, shock, cardiac arrest Signs hemorrhage: coagulation failure: bleeding from incisions, venipuncture sites, trauma (lacerations); petechiae, ecchymoses, purpura uterine atony Interventions Oxygenate: administer oxygen by face mask 8-10L/min or resuscitation bag delivering 100% oxygen Prepare for intubation and mechanical ventilation Initiate or assist with cardiopulmonary resuscitation. Tilt pregnant woman 30 degrees to side to displace uterus. Maintain cardiac output and replace fluid losses: Position woman on her side Administer IV fluids Administer blood: packed cells, fresh frozen plasma Insert indwelling catheter, and measure hourly urine output Correct coagulation failure Monitor fetal and maternal status Prepare for emergency birth once woman's condition is stabilized Provide emotional support to woman, her partner, and her family |
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Placenta Accreta
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A placenta in which the cotyledons have invaded the uterine musculature, resulting in difficult or impossible separation of the placenta.
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placental increta
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A form of placenta accreta in which the chorionic villi invade the myometrium
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placental percreta
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A type of placenta accreta in which the myometrium is invaded to the serosa of the peritoneum covering the uterus. This may cause rupture of the uterus.
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Emotions (psyche)
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excessive fear
excessive anxiety grief stress hormones can affect labor progress psyche plays huge role in labor progress |
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Preterm labor: definition
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Preterm labor is defined as cervical changes and uterine contractions occurring between 20 weeks and 37 weeks of pregnancy.
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Preterm labor: risk factors
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Preexisting--previous preterm labor or birth
second trimester abortion (more than two spontaneous or therapeutic); stillbirths Grand multiparity; short interval between pregnancies (less than or equal to 1 year since last birth) Progesterone deficiency Uterine anomalies or fibroids; uterine irritability Cervical incompetence, trauma, shortened length Exposure to DES or other toxic substances Medical diseases (e.g., diabetes, hypertension, anemia) Small stature (<119 cm in height; <45.5 kg or underweight for height) Current pregnancy risks: multifetal pregnancy hydramnios bleeding placental problems (e.g., placenta previa, abruptio placentae) infections (e.g., pyelonephritis, recurrent UTIs, asymptomatic bacteriuria, bacterial vaginosis, chorioamnionitis) gestational hypertension premature rupture of the membranes fetal anomalies inadequate plasma volume expansion; anemia |
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Preterm labor: signs and symptoms
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Uterine Activity
uterine contractions more frequent than every 10 minutes persisting for 1 hour or more Uterine contractions may be painful or painless Discomfort: lower abdominal cramping similar to gas pains; may be accompanied by diarrhea Dull, intermittent low back pain (below the waist) painful, menstrual-like cramps suprapubic pain or pressure pelvic pressure or heaviness urinary frequency Vaginal discharge: change in character and amount of usual discharge: thicker (mucoid) or thinner (watery), bloody, brown or colorless, increased amount, odor Rupture of amniotic membranes |
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Preterm labor: assessment
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the diagnosis of preterm labor is based on three major diagnostic criteria:
Gestation of 20 to 37 weeks Uterine activity (contractions) Progressive cervical change (e.g., cervical effacement of 80% or cervical dilation of 2 cm or greater) |
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Preterm labor: management medications
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It is now thought that the best reason to use tocolytics is that they afford the opportunity to begin administering antenatal glucocorticoids to accelerate fetal lung maturity and reduce the severity of sequelae in infants born preterm.
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Preterm labor: management medications
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The medications most commonly used for this purpose are ritodrine (yutopar), terbutaline (Brethine), magnesium sulfate, indomethacin (Indocin), and nifedipine (Procardia).
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Preterm labor: management
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Nurses caring for women with symptoms of preterm labor should question the women about whether they have symptoms when engaged in any of the following activities:
sexual activity riding long distances in automobiles, trains, or buses carrying heavy loads such as laundry, groceries, or a small child standing more than 50% of the time heavy housework climbing stairs hard physical work being unable to stop and rest when tired |
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Post term labor: definition
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>42 weeks gestation
Clinical manifestations of postterm pregnancy include maternal weight loss, decreased uterine size (because of decreased amniotic fluid), meconium in the amniotic fluid, and advanced bone maturation of the fetal skeleton with an exceptionally hard fetal skull. |
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Post term labor: risks
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Maternal risks are often related to the birth of an excessively large infant. The woman is at increased risk for dysfunctional labor; birth canal trauma, including perineal lacerations and extension of episiotomy during vaginal birth; postpartum hemorrhage; and infection.
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Post term labor: interventions
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Interventions such as induction of labor with prostaglandins or oxytocin, vacuum- or forceps-assisted birth, and cesarean birth are more likely to be necessary. The woman may also experience fatigue and psychologic reactions such as depression, frustration, and feelings of inadequacy as she passes her estimated date of birth.
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Post term labor: fetal risks
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Fetal risks appear to be twofold. The first is the possibility of prolonged labor, shoulder dystocia, birth trauma, and asphyxia from macrosomia, which is estimated to occur in approximately 25% of prolonged pregnancies. The second risk is the compromising effects on the fetus of an "aging" placenta. Placental function gradually decreases after 37 weeks of gestation. Amniotic fluid volume declines to approximately 800 mL by 40 weeks of gestation and to about 400 mL by 42 weeks of gestation. The resulting oligohydramnios can lead to fetal hypoxia related to cord compression. If placental insufficiency is present, there is a high likelihood of fetal distress occurring during labor. Neonatal problems may include asphyxia, meconium aspiration syndrome, dysmaturity syndrome, hypoglycemia, polycythemia, and respiratory distress. whether an infant boran after a postterm pregnancy has neurologic, behavioral, intellectual, or developmental problems must be further investigated.
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