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160 Cards in this Set

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  • Back
Why use EFM?
It's a useful tool for visualizing FHR patterns on a monitor screen or printed tracing.
How can fetal O2 supply decrease?
- Decrease of blood flow through maternal vessels
- Decrease of O2 content in maternal blood as a result of hemorrhage or severe anemia -- Alteration in fetal circulation
- Decreased blood flow to the intervillous space in the placenta
What can decreased blood flow through the maternal vessels result in?
- Hypotension (caused by supine maternal position, hemorrhage, or epidural analgesia or anesthesia)
- Hypovolemia (caused by hemorrhage)
What can decrease the O2 content in maternal blood?
- hemorrhage
- severe anemia
What are some alterations in fetal circulation?
Compression of the umbilical cord, Placental separation or complete abruption, Head Compression
What causes a decrease in blood flow to the intervillous space in the placenta?
Excessive exogenous oxytocin, Deteriorization of the placental vasculature associated with maternal disorders such as HTN or diabetes mellitus.
How can fetal well-being during labor be measured?
By the response of the FHR to uterine contractions (UC).
What are reassuring FHR patterns characterized by?
A baseline FHR in the range 110-160 beats/min, Accelerations of FHR with fetal movement.
What is a normal uterine activity pattern in labor characterized by?
Contractions occurring every 2 to 5 minutes and lasting less than 90 seconds.
What are the goals of intrapartum FHR monitoring?
To indentify nonreassuring patterns indicative of fetal compromise.
What are nonreassuring FHR patterns associated with?
Fetal hypoxia and Anoxia (inadequate supply of O2 at the cellular level)
What are some fetal monitoring techniques?
Intermittent Auscultation (IA) and Electronic Fetal Monitoring (EFM), external and internal
Intermittent Auscultation (IA)
Uses listening to fetal heart sounds at periodic intervals to assess FHR.
External Electronic Fetal Monitoring
FHR is monitored with an ultrasound transducer, The tocotransducer measures uterine activity transabdominally
Internal Electronic Fetal Monitoring
Spinal electrode: converts the fetal ECG to the FHR, Intrauterine pressure catheter (IUPC): monitors the frequency, duration, and intensity of contractions.
Do the membranes need to be ruptured in order to use internal electronic fetal monitoring?
What is the average pressure during a contraction?
50 to 85 mmHg
What controls the FHR?
Rhythmicity of the fetal heart, Central nervous system (CNS), Fetal autonomic nervous system control
What does an increase in sympathetic response result in?
Acceleration of the FHR
What does an augmentation in parasympathetic response produce?
Slowing of the FHR
Baseline fetal heart rate
The average rate during a 10-minute segment that excludes periodic or episodic changes, periods of marked variability, and segments of the baseline that differ by more than 25 beats/min. Normal range is 110-160 beat/min.
Variation of differing rhythmicity in the heart rate over time and is reflected on the FHR tracing as a slight irregularity or "jitter" wave.
What is the most reliable indicator of fetal well-being?
What is LTV?
Long-term variability is based on visualization of the amplitude of the FHR in the peak to trough segment in beats per minute.
What is absence or undetected variability considered?
It's considered not reassuring and a sign of fetal distress unless it has an identifiable cause.
Tachycardia (FHR)
Baseline more than 160bpm for duration of 10 minutes or longer
Bradycardia (FHR)
Baseline less than 110 bpm for duration of 10 minutes or longer.
What are 2 types of changes in FHR?
- Periodic: Occur with uterine contraction
- Episodic: not associated with uterine contractions
An abrupt increase of the FHR 15 beats/min or greater and lasts 15 seconds or more, with a return to baseline less than 2 minutes from the beginning of the acceleration.
When are accelerations considered a change in baseline?
Accelerations for more than 10 minutes.
What is happening when a baby has an acceleration?
It's the result of the pressure of the contraction applied to the fetal buttocks.
What results in decelerations?
Pressure applied to the head.
What can episodic accelerations be associated with?
Breech presentations
FHR patterns
They can be benign or nonreassuring.

There are three types of decels:
1. Late decelerations
2. Variable decelerations
3. Early decelerations
Early decelerations
Response to fetal compression
How are FHR decelerations described?
By their visual relation to the onset and end of a contraction and by their shape.
Late decelerations
Due to uteroplacental insufficiency. The deceleration begins after the contraction has started, and the lowest point of deceleration occurs after the peak of contraction.
Variable decelerations
Response to umbilical cord compression
Prolonged decelerations
A decrease of the FHR below the baseline 15 beats/min or more and lasting more than 2 minutes but less than 10 minutes.
What causes variable decelerations?
Cord compression; they tend to have a U or V shape.
What is shouldering?
A compensatory response to compression of the umbilical cord.
Intrauterine resuscitation
Referring to interventions initiated when nonreassuring FHR patterns are recognized.
Nursing management of nonreassuring patterns
- Open maternal and fetal vascular system (assist woman to side-lying position)
- Increase blood volume (by increasing the rate of the primary IV)
- Provide O2 by face mask at 8-10L
- Resting the uterus by d/c pitocin, administering tocolytics
Meds used to supress premature labor.
Nursing management of nonreassuring patterns
They are directed primarily toward improving uterine and intervillous space blood flow and secondarily toward increased maternal oxygenation and cardiac output.
Additional methods of assessment and intervention for nonreassuring patterns
- Fetal HR response to stimulation (via acoustic stimulation or scalp stimulation)
- Fetal O2 monitoring via Fetal Pulse Oximetry (FPO)
- Amnioinfusion
- Tocolytic therapy (By using mag or terb)
- Umbilical cord acid-base determination
- avoiding supine position and position changes
- discourage the valsalva maneuver
Definition of preterm labor
Cervical changes and uterine contractions occurring between 20-37 weeks gestation.
Preterm Birth
Birth before 37 weeks gestation
less than 2500 grams
S/S of preterm labor
- Uterine contractions every 10 minutes or more frequently
- pelvic pressure
- dull lower back pain
- change in vaginal discharge
- ANY pain or pressure in the pelvis or back that comes and goes with any regularity
What are the 3 major diagnostic criteria for preterm labor?
1. Gestational age between 20 and 37 weeks
2. Contractions
3. Progressive cervical change: effacement of 80% and/or cervical dilation of 2cm or greater.
What is the number one cause of risk for preterm labor?
What are other causes or risk factors for preterm labor?
- Substance abuse
- Poor nutrition
- Age
- Short cervix
- Race, economic status
- Multiple gestation
What lifestyle activities can result in preterm labor symptoms?
- Sexual activity
- Carryling heavy loads
- Standing more than 50% of the time
- Heavy housework or climbing stairs
- Hard physical work
- Being unable to stop and rest when tired
What is commonly recommended for the prevention of preterm labor but has not been proven effective?
Antenatal glucocorticoids
Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. It is viewed as a form of care likely to be beneficial (Enkin et al, 2000). This class of medications also seems to decrease rates of intraventricular hemorrhage in preterm infants. All women between 24 and 34 weeks of gestation should be given antenatal glucocorticoids when preterm birth is threatened, unless there is a medical indication for immediate delivery such as cord prolapse, chorioamnionitis, or abruptio placentae.
What are some types of tocolytics?
- Terbutaline: smooth muscle relaxer, inhibits uterine contractions, watch for tachycardia, SOB, and tachypnea
- Magnesium Sulfate: CNS depressant, smooth muscle relaxant
- Ritodrine: smooth muscle relaxer
smooth muscle relaxer, inhibits uterine contractions, watch for tachycardia, SOB, and tachypnea
Magnesium Sulfate
CNS depressant, smooth muscle relaxant
smooth muscle relaxer
What are some maternal contraindications to tocolysis?
Severe PIH or eclampsia, active vaginal bleeding, intrauterine infection, cardiac disease, dilation greater than 6 cm
What are some fetal contraindications to tocolysis?
Fetal death/lethal fetal anomaly, acute fetal distress, chronic IUGR, gestational age greater than 34 weeks
Management of inevitable preterm birth
- Labor progressed to cervical dilation of 4 cm likely to lead to inevitable preterm birth
- Preterm births in tertiary care centers lead better neonatal and maternal outcomes
- Women at risk should be transferred quickly to ensure best possible outcome
Premature rupture of membranes: Rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of labor at any gestational age.
Preterm Premature Rupture of Membranes (PPROM)
- Membranes rupture before 37 weeks of gestation
- Occurs in up to 25% of preterm labor cases
- Often preceded by infection
- Etiology unknown
- Diagnosed after woman complains of sudden gush or slow leak of vaginal fluid
Defined as long, difficult, or abnormal labor. It's dysfunctional labor from abnormal uterine contractions preventing normal progress of: cervical dilation, effacement (primary powers), and descent (secondary powers).

Dystocia increases in obese or short women.
What can increase the risk for uterine dystocia?
- Body build (short/heavy)
- Uterine abnormalities
- Malpresentation and position of the fetus
- Overstimulation with oxytocin
- Cephalopelvic disproportion (CPD)
- Maternal fatigue, dehydration and electrolyte imbalance, and fear
- Inappropriate timing of analgesic or anesthetic administration
What does dysfunction of the uterine contractions include?
- hypertonic or primary dysfunctional labor
- hypotonic or secondary uterine inertia
What types of dystocia can be related to the secondary powers?
- Bearing down efforts are compromised when large amounts of analgesia are given
- Analgesics may also block the bearing-down reflex
Types of dystocia related to alterations in pelvic structure
- Pelvic dystocia
- soft-tissue dystocia
pelvic dystocia
Pelvic dystocia can occur whenever there are contractures of the pelvic diameters that reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.

Disproportion of the pelvis is the least common cause of dystocia. Pelvic contractures may be caused by congenital abnormalities, maternal malnutrition, neoplasms, or lower spinal disorders. An immature pelvic size predisposes some adolescent mothers to pelvic dystocia. Pelvic deformities may also be the result of automobile or other accidents or trauma.
Soft-tissue dystocia
Soft-tissue dystocia results from obstruction of the birth passage by an anatomic abnormality other than that involving the bony pelvis. The obstruction may result from placenta previa (i.e., low-lying placenta) that partially or completely obstructs the internal os of the cervix. Other causes, such as leiomyomas (uterine fibroids) in the lower uterine segment, ovarian tumors, and a full bladder or rectum, may prevent the fetus from entering the pelvis. Occasionally, cervical edema occurs during labor when the cervix is caught between the presenting part and the symphysis pubis or when the woman begins bearing-down efforts prematurely, inhibiting complete dilation. Sexually transmitted infections (e.g., human papillomavirus) can alter cervical tissue integrity and thus interfere with adequate effacement and dilation.
Fetal causes of dystocia
- anomalies
- cephalopelvic disproportion (CPD)
- Malposition
- Malpresentation
- Multifetal pregnancy
What happens if the dystocia cannot be overcome?
Medical interventions for malpresentation
- External cephalic version
- Internal cephalic version
External cephalic version
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. Before it is attempted, ultrasound scanning is done to determine the fetal position; locate the umbilical cord; rule out placenta previa; evaluate the adequacy of the maternal pelvis; and assess the amount of amniotic fluid, the fetal age, and the presence of any anomalies. A nonstress test (NST) is performed to confirm fetal well-being, or the FHR is monitored for a time (usually 10 to 20 minutes). Informed consent is obtained. Contraindications to ECV include uterine anomalies, previous cesarean birth, CPD, placenta previa, multifetal gestation, and oligohydramnios. ECV performed at term to avoid breech birth is a beneficial form of care.
Internal cephalic version
With internal version, the fetus is turned by the physician, who inserts a hand into the uterus and changes the presentation to cephalic (head) or podalic (foot). Internal version may be used in multifetal pregnancies to deliver the second fetus. The safety of this procedure has not been documented; maternal and fetal injury is possible. Cesarean birth is the usual method for managing malpresentation in multifetal pregnancies. The nurse's role is to monitor the status of the fetus and to provide support to the woman.
Interventions for labor dystocia
- monitor contractions and FHR
- Position of the woman
- Augment or induce labor
- C-section
- Psychologic responses (hormones and neurotransmitters released in response to stress can cause dystocia)
- Abnormal labor patterns
Precipitous labor
Precipitous labor is defined as labor that lasts less than 3 hours from the onset of contractions to the time of birth. It is an abnormal labor pattern.Precipitous labor occurred at the highest rate among women age 35 to 39 and at the lowest rate among women younger than 20 years.
What may cause precipitous labor?
Precipitous labor may result from hypertonic uterine contractions that are tetanic in intensity. Maternal and fetal complications can occur as a result. Maternal complications include uterine rupture, lacerations of the birth canal, amniotic fluid embolism, and postpartum hemorrhage. Fetal complications include hypoxia, caused by decreased periods of uterine relaxation between contractions, and intracranial hemorrhage related to rapid birth.

Women who have experienced precipitate labor often describe feelings of disbelief that their labor began so quickly, alarm that their labor progressed so rapidly, panic about the possibility they would not make it to the hospital on time to give birth, and finally relief when they arrived at the hospital. In addition, women have expressed frustration when nurses would not believe them when they reported their readiness to push.
Trial of labor
A trial of labor (TOL) is the observance of a woman and her fetus for a reasonable period (e.g., 4 to 6 hours) of spontaneous active labor to assess the safety of vaginal birth for the mother and infant. TOL may be initiated if the mother's pelvis is of questionable size or shape, if she wishes to have a vaginal birth after a previous cesarean birth, or if the fetus is in an abnormal presentation. It is a form of care likely to be beneficial when implemented after a previous low-segment cesarean birth. Fetal sonography or maternal pelvimetry (or both) may be done before a TOL to rule out CPD. The cervix must be ripe (soft and dilatable). During a TOL, the woman is evaluated for the occurrence of active labor, including adequate contractions, engagement and descent of the presenting part, and effacement and dilation of the cervix.

The nurse assesses maternal vital signs, fetal heart rate and pattern and is alert for signs of potential complications. If complications develop, the nurse is responsible for initiating appropriate actions, including notifying the primary health care provider, and for evaluating and documenting the maternal and fetal responses to the interventions. Supporting and encouraging the woman and her partner and providing information regarding progress can reduce stress, enhance the labor process, and facilitate a successful outcome.
Induction of labor
Induction of labor can be elective (for the convenience of the patient or staff) or indicated for medical, obstetric, or fetal reasons. Induction of labor is the chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about the birth. 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. Under such conditions the risk to the mother or fetus is less than the risk of continuing the pregnancy.

Both chemical and mechanical methods are used to induce labor. Intravenous oxytocin and amniotomy are the most common methods used in the United States. Prostaglandins are increasingly used for inducing labor. The most effective protocol (e.g., dose, frequency) to follow when using prostaglandins continues to be investigated.

Less commonly used methods include nipple stimulation (manual or with a breast pump), the ingestion of castor oil or herbal preparations, a soapsuds enema, stripping of membranes, and acupuncture. Many folk beliefs exist regarding methods to induce labor. These methods include activity (e.g., walking, exercise, strenuous work, sexual intercourse), fasting, and increasing stress (e.g., frightening the woman). It is important for the nurse to know the practices a woman may believe in and follow, because some of these methods can be harmful (e.g., strenuous activity).
Augmentation of labor
Augmentation of labor is the stimulation of uterine contractions after labor has started spontaneously but progress is unsatisfactory. Augmentation is usually implemented for the management of hypotonic uterine dysfunction resulting in a slowing of labor (protracted active phase). Common augmentation methods include oxytocin infusion, amniotomy, and nipple stimulation. Noninvasive methods such as emptying the bladder, ambulation and position changes, relaxation measures, nourishment and hydration, and hydrotherapy should be attempted before invasive interventions are initiated. The procedures and nursing assessments are similar to those used for oxytocin induction of labor.
Types of Mechanical dilators
- Balloon catheter
- laminaria
- Lamicel (synthetic that contains magnesium sulfate)
- Hygroscopic dilators
Balloon catheter
Balloon catheters (e.g., Foley catheter) can be inserted into the intracervical canal to ripen and dilate the cervix.
Laminaria tents (natural cervical dilators made from seaweed) and synthetic dilators containing magnesium sulfate (Lamicel) are inserted into the endocervix without rupturing the membranes. As they absorb fluid, they expand and cause cervical dilation. These dilators are left in place for 6 to 12 hours before being removed to assess cervical dilation. Fresh dilators are inserted if further cervical dilation is necessary. Synthetic dilators swell faster than natural dilators and become larger with less discomfort. Nursing responsibilities for women who have dilators inserted include documenting the number of dilators and sponges inserted during the procedure, as well as the number removed, and assessment for urinary retention, rupture of membranes, uterine tenderness/pain, contractions, vaginal bleeding, and fetal distress.
Hygroscopic dilators
Hygroscopic dilators (substances that absorb fluid from surrounding tissues and enlarge) also can be used for cervical ripening.
Amniotomy (i.e., artificial rupture of membranes [AROM]) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if progress begins to slow. Labor usually begins within 12 hours of the rupture; the duration of labor is decreased by up to 2 hours, especially if combined with oxytocin administration. However, if amniotomy does not stimulate labor, the resulting prolonged rupture may lead to infection. Once an amniotomy is performed, the woman is committed to giving birth. For this reason, amniotomy often is used in combination with oxytocin induction.

The cervix has to be 4-5 cm dilated, be vertex presentation, and head well applied to cervix.
What must be done after AROM?
Assess FHR and monitor maternal temp every 2 hours.
What produces oxytocin?
posterior pituitary gland
How is oxytocin given postpartum?
IM injection.
How is oxytocin administered?
- IV pump
- titrated up every 30-60 minutes until effective contraction pattern is established
- watch for uterine hyperstimulation and FHR
- monitor VS with each increment dose
You notice that after starting pit that the FHR is 85 and not returning to its previous baseline of 120 bpm, what do you do?
Turn patient on left side, may have to turn pit off, and give O2. Then call doc and reassess patient. Document.
forceps-assisted birth
Certain conditions are required for a forceps-assisted birth to be successful. 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. CPD should not be present.

There are different definitions of forceps applications. Outlet forceps are used when the fetal scalp is visible on the perineum without manually separating the labia. Outlet forceps are used to shorten the second stage of labor (Fig. 19-8). Low forceps refers to the application of forceps to a fetal head that is at least at a +2 cm station. Midforceps is the application of forceps to the fetal head that is engaged (no higher than station 0) but above the +2 cm station. In no instances should the forceps be applied to an unengaged presenting part.
Vacuum-assisted birth
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. Indications for use are similar to those for outlet forceps. Prerequisites for use include a vertex presentation, ruptured membranes, and the absence of CPD. When an operative vaginal birth is required, vacuum assistance is preferred as a beneficial form of care when compared with forceps assistance.

When the birth is to be vacuum assisted, the woman is prepared for a vaginal birth in the lithotomy position to allow for sufficient traction. The cup is applied to the fetal head, and a caput develops inside the cup as the pressure is initiated. Traction is applied to facilitate descent of the fetal head, and the woman is encouraged to push as suction is applied. As the head crowns, an episiotomy is performed if necessary. The vacuum cup is released and removed after birth of the head. If vacuum extraction is not successful, a forceps-assisted or cesarean birth is performed.
What are the prerequisites for a vacuum-assisted birth?
- vertex presentation
- ruptured membranes
- Absence of CPD
What are the two main types of cesarean operations?
The two main types of cesarean operation are the classic and the lower segment cesarean incisions. Classic cesarean birth is rarely performed today, although it may be used when rapid birth is necessary and in some cases of shoulder presentation and placenta previa. The incision is made vertically into the upper body of the uterus. Because the procedure is associated with a higher incidence of blood loss, infection, and uterine rupture in subsequent pregnancies than is lower-segment cesarean birth, vaginal birth after a classic cesarean is contraindicated.

Lower-segment cesarean birth can be achieved through a vertical or transverse incision into the uterus. The transverse incision is more popular, however, because it is easier to perform, is associated with less blood loss and fewer postoperative infections, and is less likely to rupture in subsequent pregnancies.
***Indications for a c-section
- fetal distress (late decels, fhr less than 100bpm (brady), or more than 160 (tachy))
- malpresentation (breech or transverse)
- placenta previa or abruptio
- cord prolapse
- active genital herpes infection
- positive HIV status with pr
maternal complications and risks for c-sections
aspiration, infection, risk for injury to bladder or bowel, hemorrhage, pulmonary embolism, DVT, complication r/t anesthesia.
Post-op care for a c-section
- fundal checks, VS, lochia
- assess bonding
- encourage breastfeeding if both patients are stable
- advance diet as tolerated, check bowel sounds
- I&O
- IV oxytocin, antibiotics, analgesics
- get to ambulate
- get to void every 1-2 hours
infant complications and risks for c-sections
longer transition time, injury during surgery, less likely to breast feed
Why is it important to get a patient to void after a c-section?
A full bladder affects the ability of the uterus to contract, otherwise the uterus could get deviated to the left.
Discharge planning
- rest and sleep
- monitor temp, incision, lochia
- will need assistance with household chores
- cannot lift anything heavier than the baby
- cannot drive
- limit exercise and sexual activity
What is a postterm pregnancy?
more than 42 weeks gestation
What are some risks associated with a postterm pregnancy?
- increased risk for dysfunctional labor, traumatic labor, epis/laceration, postpartum hemorrhage and infection
- fetal risks: shoulder dystocia, asphyxia
- placenta not as functional
- oligohydramnios
Shoulder dystocia
Shoulder dystocia is a condition in which the head is born but the anterior shoulder cannot pass under the pubic arch. Fetopelvic disproportion due to excessive fetal size (greater than 4000 g) or maternal pelvic abnormalities may be a cause of shoulder dystocia, although shoulder dystocia can occur in the absence of any known risk factors.
McRoberts Maneuver
In the McRoberts maneuver, the woman's legs are flexed apart with her knees on her abdomen. This maneuver causes the sacrum to straighten, and the symphysis pubis rotates toward the mother's head; the angle of pelvic inclination is decreased, freeing the shoulder.
What can be done to free the shoulder in shoulder dystocia?
- McRoberts Maneuver
- suprapubic pressure
What are some types of suprapubic pressure?
- Mazzanti technique
- Rubin Technique
What nursing care/techniques can be used for shoulder dystocia?
Mazzanti and Rubin Technique
What are some examples of obstetric emergencies?
- Prolapsed umbilical cord
- rupture of the uterus
- amnionic fluid embolism (AFE)
Prolapse of the umbilical cord
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 rupture of membranes, when gravity washes the cord in front of the presenting part. Contributing factors are a long cord (longer than 100 cm), malpresentation (breech), transverse lie, or unengaged presenting part.
prolapsed cord
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 central nervous system 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. If the cervix is fully dilated, a forceps- or vacuum-assisted birth can be performed for the fetus in a cephalic presentation; otherwise a cesarean birth is likely to be performed. Nonreassuring fetal heart rate and pattern, inadequate uterine relaxation, and bleeding can also occur as a result of a prolapsed umbilical cord.
Rupture of the Uterus
Rupture of the uterus is a rare but very serious obstetric injury that occurs once in every 1500 to 2000 births. The most common causes of uterine rupture during pregnancy are separation of the scar of a previous classic cesarean birth, uterine trauma (e.g., accidents, surgery), and congenital uterine anomaly. During labor and birth, uterine rupture may be caused by intense spontaneous uterine contractions, labor stimulation (e.g., oxytocin, prostaglandin), an overdistended uterus (e.g., multifetal gestation), malpresentation, external or internal version, or a difficult forceps-assisted birth. It occurs more commonly in multigravidas than primigravidas.
S/S of uterine rupture
- Possible non-reassuring FHR, decels, decreased variability
- Mother: nausea, vomitting, abdominal tenderness, sharp pain, pale skin
Treatment for uterine rupture
If it is a complete rupture, hysterectomy and blood transfusion.
Amniotic Fluid Embolism (AFE)
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. This can occur because fluid can enter the maternal circulation any time there is an opening in the amniotic sac or maternal uterine veins accompanied by enough intrauterine pressure to force the amniotic fluid into the veins.
S/S of AFE
Restlessness, dyspnea, cyanosis, hypotension, tachycardia, coagulation failure, uterine atony.
Nursing interventions for AFE
- O2 via face mask, prep for intubation
- Position woman on her side
- Admin IV fluids and blood products
- Strict I&O (foley cath)
If the uterus can't stop the blood loss, what is usually done?
Methergine is given.
What is involution?
The return of the uterus to a nonpregnant state following birth is termed involution. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle.
Where is the uterus at the end of the third stage of labor?
At the end of the third stage of labor, the uterus is in the midline, approximately 2 cm below the level of the umbilicus, with the fundus resting on the sacral promontory. At this time, the uterus weighs approximately 1000 g.
What are responsible for stimulating the massive growth of the uterus during pregnancy?
Increased estrogen and progesterone levels
What does a decrease in estrogen and progesterone cause?
Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain and account for the slight increase in uterine size after each pregnancy.
What is subinvolution?
Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.
What is postpartum hemostasis achieved by?
Postpartum hemostasis is achieved primarily by compression of intramyometrial blood vessels as the uterine muscle contracts, rather than by platelet aggregation and clot formation. The hormone oxytocin, released from the pituitary gland, strengthens and coordinates these uterine contractions, which compress blood vessels and promote hemostasis. During the first 1 to 2 postpartum hours, uterine contractions may decrease in intensity and become uncoordinated. Because it is vital that the uterus remain firm and well contracted, exogenous oxytocin (Pitocin) is usually administered intravenously or intramuscularly immediately after expulsion of the placenta. Mothers who plan to breastfeed may be encouraged to put the baby to breast immediately after birth because suckling stimulates oxytocin release.
What can a multiparous mother experience after she gives birth?
Periodic relaxation and vigorous contractions are more common in subsequent pregnancies and may cause uncomfortable cramping called afterpains (afterbirth pains), which persist throughout the early puerperium. Afterpains are more noticeable after births in which the uterus was greatly distended (e.g., large baby, multifetal gestation). Breastfeeding and exogenous oxytocic medication usually intensify these afterpains because both stimulate uterine contractions.
What is lochia?
Postbirth uterine discharge, commonly called lochia, initially is bright red and changes later to a pinkish red or reddish brown. It may contain small clots. For the first 2 hours after birth the amount of uterine discharge should be about that of a heavy menstrual period. After that time, the lochia flow should steadily decrease.
What are the different types of lochia?
Lochia rubra consists mainly of blood and decidual and trophoblastic debris. The flow pales, becoming pink or brown (lochia serosa) after 3 to 4 days. Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. The median duration of lochia serosa discharge is 22 to 27 day. In most women, about 10 days after childbirth the drainage becomes yellow to white (lochia alba). Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. Lochia alba may continue for 2 to 6 weeks after the birth.
What would persistence of lochia rubra early in the postpartum period suggest?
Persistence of lochia rubra early in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. Recurrence of bleeding 7 to 10 days after birth is from the healing placental site. About 10% to 15% of women will still be having normal lochia serosa discharge at their 6-week postpartum examination. In the majority of women, however, the continued flow of lochia serosa or lochia alba by 3 to 4 weeks after birth may indicate endometritis, particularly if fever, pain, or abdominal tenderness is associated with the discharge. Lochia should smell like normal menstrual flow; an offensive odor usually indicates infection
What happens to the content of the urine after a baby is delivered?
The renal glycosuria induced by pregnancy disappears, but lactosuria may occur in lactating women. The blood urea nitrogen (BUN) increases during the puerperium as autolysis of the involuting uterus occurs. This breakdown of excess protein in the uterine muscle cells also results in a mild (+1) proteinuria for 1 to 2 days after childbirth in approximately 50% of women. Ketonuria may occur in women with an uncomplicated birth or after a prolonged labor with dehydration.
Renal glycosuria
Renal glycosuria, also known as renal glucosuria, is a rare condition in which the simple sugar glucose is excreted in the urine despite normal or low blood glucose levels. With normal kidney (renal) function, glucose is excreted in the urine only when there are abnormally elevated levels of glucose in the blood. However, in those with renal glycosuria, glucose is abnormally eliminated in the urine due to improper functioning of the renal tubules, which are primary components of nephrons, the filtering units of the kidneys.
Postpartal diuresis
Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in the lower extremities, and loss of the remaining pregnancy-induced increase in blood volume, also aids the body to rid itself of excess fluid.
What causes breast size to increase postpartum?
What does pregnancy induced Hypovolemia allow for?
A 500mL loss of blood for a vaginal birth. (More blood is lost during a C-section)
What happens to the hematocrit and hemoglobin levels after delivery?
They both increase 72 hours after delivery due to greater concentration of RBCs. They usually return to normal by 8 weeks pp.
Besides RBCs, what else are elevated after giving birth?
WBCs are elevated for the first 10-12 days pp. Clotting factors and fibrinogen are elevated, increasing the risk for thromboembolism.
When does the uterus return to the true pelvis?
Within 2 weeks.
What is the most frequent cause of excessive bleeding after childbirth?
The most frequent cause of excessive bleeding after childbirth is uterine atony, or failure of the uterine muscle to contract firmly.
What are the two most important interventions for preventing excessive bleeding after delivery of the placenta?
The two most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention.
What is a major intervention for uterine atony?
A major intervention to restore good tone is stimulation by gently massaging the uterine fundus until firm. Fundal massage may cause a temporary increase in the amount of vaginal bleeding seen as pooled blood leaves the uterus. Clots may also be expelled. Fundal massage can be a very uncomfortable procedure. Understanding the causes and dangers of uterine atony and the purpose of fundal massage can help the woman be more cooperative. Teaching the patient to massage her own fundus enables her to maintain some control and decreases her anxiety.
What happens if the uterus may remain boggy even after massage and expulsion of clots?
If this occurs, it is a major warning sign of uterine atony. The nurse must remain with the woman and summon help, including notifying the primary health care provider immediately. Additional interventions likely to be used are administration of intravenous fluids and oxytocic medications (drugs that stimulate contraction of the uterine smooth muscle).
The three phases of maternal postpartum adjustment
The three phases are 1. dependent: taking-in, 2. dependent/independent: taking-hold, and 3. Interdependent: letting go.
Dependent: taking-in
During the first 24 to 48 hours after childbirth, the mother's dependency needs predominate. To the extent that these needs are met by others, the mother is able to divert her psychologic energy to her infant rather than to focus it on herself. She needs “mothering” herself to “mother.” Rubin aptly described these few days as the taking-in phase, a time when the new mother requires nurturing and protective care. In Rubin's classic description, the taking-in phase lasted 2 to 3 days. Later studies found that women move more rapidly through the taking-in phase. This dependent phase is a time of great excitement during which parents need to verbalize their experience of pregnancy and birth. Focusing on, analyzing, and accepting these experiences help the parents move on to the next phase. Some parents use staff members or other mothers as an audience, whereas others are more comfortable talking with family and friends about the pregnancy and birth experience.
Dependent/independent: taking-hold
If the mother has received adequate nurturing in the first few hours or days, by the second or third day, her desire for independent action reasserts itself. In the dependent- independent phase, the mother alternates between a need for extensive nurturing and acceptance by others and the desire to “take charge” once again. She responds enthusiastically to opportunities to learn and to practice baby care or, if she is an accomplished mother, to carry out or direct this care. Rubin described this phase as the taking-hold phase, and noted that it lasts approximately 10 days. Most mothers are discharged home during this dependent-independent phase. Once home, mothers must continue to cope with physical adaptations and psychologic adjustments. Many mothers identify fatigue as their major physical concern. This fatigue affects various aspects of their lives, such as their relationships with their husbands and other family members and household responsibilities. Because of the relation of fatigue to postpartum depression (PPD), nurses must screen women for psychologic and physical signs and symptoms of fatigue.
Interdependent: letting go
In this phase, interdependent behavior reasserts itself, and the mother and her family move forward as a unit with interacting members. The relationship of the partners, although altered by the introduction of a baby, resumes many of its former characteristics. A primary need is to establish a lifestyle that both includes and, in some respects, excludes the baby. The couple needs to share interests and activities that are adult in scope. The interdependent phase, termed the letting-go phase, is often stressful for the parental pair. Interests and needs often diverge during this time. Women and their partners must resolve the effects of their individual roles related to child-rearing, homemaking, and careers on their relationship. Mothers (and partners) may take a more traditional role in an effort to adapt to parenthood. A special continuing effort has to be made to strengthen the adult-adult relationship as a basis for the family unit.
If lochia has a foul odor, what does it indicate?
An infection.
What is the most frequent cause of bleeding after childbirth?
Uterine atony
What are the two interventions for uterine atony?
Maintain good uterine tone and Prevent bladder distention
What do you need to check for with an episiotomy/laceration/suture?
Check for REEDA (Redness, edema, ecchymosis, drainage, approximation)
Contraindications for breastfeeding
Cancer therapy, any radioactive isotopes, Active TB, Herpes lesion on breast, HIV+ mother, Galactosemia in infant, Substance abuse, and Maternal leukemia
Postpartum Blues
The “pink” period surrounding the first day or two after birth, characterized by heightened joy and feelings of well-being, is often followed by a “blue” period. Approximately 50% to 80% of women of all ethnic and racial groups experience the postpartum blues or “baby blues". During the blues, women are emotionally labile and often cry easily for no apparent reason. This lability seems to peak around the fifth day, subsiding by the tenth day. Other symptoms of postpartum blues include depression, a let-down feeling, restlessness, fatigue, insomnia, headache, anxiety, sadness, and anger. A reduced level of circulating glucocorticoids or a subclinical hypothyroidism may exist during the puerperium. Biochemical, psychologic, social, and cultural factors have been explored as possible causes of the postpartum depressive state; however, the etiology remains unknown.

Whatever the cause, the early postpartum period appears to be one of emotional and physical vulnerability for new mothers, who may be psychologically overwhelmed by the reality of parental responsibilities. The mother may feel deprived of the supportive care she received from family members and friends during pregnancy. Some mothers regret the loss of the mother-unborn child relationship and mourn its passing. Still others have a let-down feeling when labor and birth are complete. The majority of women experience fatigue after childbirth, which is compounded by the around-the-clock demands of the new baby and can accentuate the feelings of depression.
Postpartum Depression
Approximately 10% to 15% of women experience a more severe syndrome called postpartum depression (PPD). The symptoms can range from mild to severe, with women having “good days” and “bad days.” All symptoms can be equally distressing and make the woman feel as if she is “going mad.” PPD leaves the woman with feelings of failure, overwhelming guilt, loneliness, and low self-esteem. Nurses need to teach women how to differentiate symptoms of the “blues” and PPD and should urge women to report depressive symptoms promptly if they occur. PPD can go undetected because new mothers generally do not voluntarily admit to this kind of emotional distress out of embarrassment, guilt, or fear. Nurses must be active listeners and compassionate intermediaries in interactions with new mothers so that symptoms of depression can be recognized early, assessed, and treated. Through careful attention to holistic health histories, nurses can identify women who are at high risk for PPD
Erikson - birth to 1 year
Trust vs. mistrust (birth to 1 year)— The first and most important attribute to develop for a healthy personality is a basic trust. Establishment of basic trust dominates the first year of life and describes all of the child's satisfying experiences at this age. Corresponding to Freud's oral stage, it is a time of “getting” and “taking in” through all the senses. It exists only in relation to something or someone; therefore consistent, loving care by a nurturing person is essential to development of trust. Mistrust develops when trust-promoting experiences are deficient or lacking or when basic needs are inconsistently or inadequately met. Although shreds of mistrust are sprinkled throughout the personality, from a basic trust in parents stems trust in the world, other people, and oneself. The result is faith and optimism.
Erikson - 1 to 3 years
Autonomy vs. shame and doubt (1 to 3 years)— Corresponding to Freud's anal stage, the problem of autonomy can be symbolized by the holding on and letting go of the sphincter muscles. The development of autonomy during the toddler period is centered around children's increasing ability to control their bodies, themselves, and their environment. They want to do things for themselves, using their newly acquired motor skills of walking, climbing, and manipulating and their mental powers of selection and decision making. Much of their learning is acquired through imitating the activities and behavior of others. Negative feelings of doubt and shame arise when children are made to feel small and self-conscious, when their choices are disastrous, when others shame them, or when they are forced to be dependent in areas in which they are capable of assuming control. The favorable outcomes are self-control and willpower.
Erikson - 3 to 6 years
Initiative vs. guilt (3 to 6 years)— The stage of initiative corresponds to Freud's phallic stage and is characterized by vigorous, intrusive behavior; enterprise; and a strong imagination. Children explore the physical world with all their senses and powers. They develop a conscience. No longer guided only by outsiders, there is an inner voice that warns and threatens. Children sometimes undertake goals or activities that are in conflict with those of parents or others, and being made to feel that their activities or imaginings are bad produces a sense of guilt. Children must learn to retain a sense of initiative without impinging on the rights and privileges of others. The lasting outcomes are direction and purpose.
Erikson - 6 to 12 years
Industry vs. inferiority (6 to 12 years)— The stage of industry is the latency period of Freud. Having achieved the more crucial stages in personality development, children are ready to be workers and producers. They want to engage in tasks and activities that they can carry through to completion; they need and want real achievement. Children learn to compete and cooperate with others, and they learn the rules. It is a decisive period in their social relationships with others. Feelings of inadequacy and inferiority may develop if too much is expected of them, or if they believe that they cannot measure up to the standards set for them by others. The ego quality developed from a sense of industry is competence.
Erikson - 12 to 18 years
Identity vs. role confusion (12 to 18 years)— Corresponding to Freud's genital period, the development of identity is characterized by rapid and marked physical changes. Previous trust in their bodies is shaken, and children become overly preoccupied with the way they appear in the eyes of others as compared with their own self-concept. Adolescents struggle to fit the roles they have played and those they hope to play with the current roles and fashions adopted by their peers, to integrate their concepts and values with those of society, and to come to a decision regarding an occupation. Inability to solve the core conflict results in role confusion. The outcome of successful mastery is devotion and fidelity to others and to values and ideologies.
Postmature (postterm) infant - definition
An infant born after 42 weeks of gestational age, regardless of birth weight
Characteristics of the postmature infant
Postmaturity can be associated with placental insufficiency, resulting in a newborn who has a thin, emaciated appearance (dysmature) at birth because of loss of subcutaneous fat and muscle mass. There may be meconium staining of the fingernails, the hair and nails may be long, and vernix may be absent. The skin may peel off. Not all postmature infants show signs of dysmaturity; some continue to grow in utero and are large at birth.

Perinatal mortality is significantly higher in the postmature fetus and neonate. During labor and birth, increased oxygen demands of the postmature fetus may not be met. Insufficient gas exchange in the postmature placenta increases the likelihood of intrauterine hypoxia, which may result in the passage of meconium in utero, thereby increasing the risk for meconium aspiration syndrome. Of all the deaths of postmature newborns, one-half occur during labor and birth, about one-third occur before the onset of labor, and one-sixth occur in the newborn period.