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67 Cards in this Set

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Preterm Labor: what is it?, btwn what weeks?, what % of neonatal deaths?, when do most of these deaths occur?, what are some causes?
Defined as cervical changes and uterine contractions occurring between 20 and 37 weeks. Most serious of pregnancy complications. Account for 90% of neonatal deaths. More than 70% of these deaths occur before 32 weeks. Other conditions can cause IUGR (intrauterine growth restriction), especially uteroplacental insufficiency (not enough blood flow to placenta).
Preterm Labor
Differs from LBW (≤ 2500 g), which sometimes substitutes for preterm labor statistics
See Olds, Table 20-2, for Risk Factors for Preterm Labor
Nursing Interventions for PreTerm labor. Prevention strategies (Olds, Table 20-4) (5)
1. Educate preterm labor symptoms: Uterine activity, Discomfort, Vaginal discharge
2. Fetal fibronectin (fFN) – assist with collection
3. Counsel on lifestyle modifications (reduce stress, hard physical work, sexual activity, encourage rest periods)
4. Bed rest may be prescribed. Counsel on adverse effects. Modify the home environment
5.Suppression of uterine activity with tocolytics.
Suppression of uterine activity with tocolytics= medications that suppress uterine activity are (5) ? and when are they used?
May be used before 34 weeks. Generally delay delivery for 48 hrs to several days.
Medications generally used:
1. Terbutaline- asthma pts., (beta-mimetics, epinephrine, relaxes smooth muscle).
2. Magnesium sulfate,(lowers calcium levels)
3. Indomethacin, (NSAID, prevents prostingladin production)
4. Nifedipine- late 20’s early 30’s, (calcium channel blocker)
5. Ritrodine
How is Terbutaline given and when are tocolytics to be stoped?
Terbutaline is given by SQ injection or pump, or oral. Discontinue tocolytics at least 4 hours before birth.
Contraindications to tocolysis: (7)
1. severe PIH (all meds increase blood pressure-vasocontrictors),
2. active bleeding,
3. uterine infection,
4. cardiac disease,
5. dilation > 6 cm,
6. acute fetal distress or death,
7. chronic IUGR (intrauterine growth restriction)
Review Olds’ Drug Guide for nursing interventions (10) for women receiving magnesium sulfate therapy (Ch. 20)
1. Monitor BP
2. Therapeutic range from 4-8 mg/dL (reflexes disappear at 9-13) (RR depression at level 14) (cardiac arrest at 30 mg or above)
3. Monitor respirations, no less than 12 bpm
4. Assess knee jerk- loss of reflex is the first sign of toxicity
5. Dertermine urinary output- no less than 30 ml/hour
6. if urine or RR is low, stop IV mag
7. Monitor fetal heart tones continuously with continuous IV
8. give mag 24 hours after birth to prevent seizures, if given for preclamspsia
9. watch for mag toxcity in newborn (if mag was given close to birth)
10. keep calcium gluconate at bedside (antagonist)
Promotion of fetal lung maturity
What med is used? When does it take effect?
Antenatal glucocorticoids (betamethasone, dexamethasone).
See Olds’ Drug Guide for Betamethasone (Ch. 20).
1. Must be administered timely, as they require 24 hours to take effect (nurse should be prepared)
2. they increase surfactant production
PPROM
Preterm Premature Rupture of Membranes
PPROM,
definition?
what causes it?
what are the serious s/e?
Defined as rupture of membranes before 37 weeks. Often proceeded by infection, but etiology is unknown. Infection is the serious side effect: (1.)=life threatening to mother and fetus. Most respond well to antibiotics, but sepsis can occur. Can lead to (2.)
1. Chorioamnionitis (intra-amniotic infection resulting from bacterial invasion and inflammation of the membranes before birth.)

2. cord prolapse/compression, oligohydramnios (too little amniotic fluid, baby not urinating properly)
Nursing Interventions PPROM (6)
1. Strict sterile technique for any vaginal exam.
2. Test for rupture of membranes (nitrazine paper-ph testing will be bright purple/BLUE or FERNING b/c amniotic fluid (pH 7.4-7.5) is more alkaline than vag secretions pH 4.5 to 5.5)
3. Emotional support.
4. Frequent biophysical profiles; teach mom how to do fetal kick counts.
5. Administer glucocorticoids, IF NO INFECTION.
6. Teach strict genital hygiene, pelvic rest, hydration and s& sx of infection to report
Dysfunctional Labor Patterns: Hypertonic: what is it?, where are they?, in what phase?
painful, frequent, ineffective contractions(ineffective dilation & effacing),
-usually in the mid-uterus rather than fundus, so not effective in pushing fetus down
-occurs during the latent phase
Tx for hypertonic
therapeutic rest (warm shower, analgesics) to allow 4-6 hours of rest; likely to awaken in normal labor
Dysfunctional Labor Patterns: Hypotonic
makes normal progress, then contractions weaken or stop. If vital signs, fetal heart rate/pattern, amniotic fluid are normal, tx is...? (next slide)
Tx for hypotonic (5)
1. ambulation,
2. hydrotherapy,
3. stripping membranes,
4. nipple stimulation or
5. oxytocin infusion
CPD (cephalopelvic disproportion)
Often related to macrosomia. Can be caused by too small pelvis, or one of abnormal shape
Malposition
Most common is persistent occiput posterior position.
“Back labor” (fetal head pressing against sacrum).
Physician may try maneuvers to rotate the fetus
(see Olds, Figures 26-3 and 26-4)
Malpresentation: Breech
Interventions
1. Usually will necessitate c-section.
2. Attempt at external cephalic version:
a. Done after 37 weeks, in L&D.
b. Constant gentle pressure on abdomen.
c. Nurse monitors. FHR/pattern (esp. bradycardia and variable decels), maternal vital signs and comfort level
d. After the version, continue to monitor vitals, FHR/pattern, uterine activity, assess for vaginal bleeding
Precipitate labor
Defined as labor lasting less than 3 hours from onset of contractions to time of birth
Maternal complications of precipitate labor: (4)
1.uterine rupture,
2. lacerations of birth canal,
3. amniotic fluid embolism,
4. postpartum hemorrhage.

**Listen to the mother when she says she feels need to push!
Fetal complications from precipitate labor: (2)
1. hypoxia (pressure of frequent contractions) and
2. intracranial hemorrhage from rapid birth
Critical for nurse to maintain good nursing care (for medico-legal risks) (5)
1. Clear documentation
2. Assess for informed consent
3. Provide full explanations of all procedures, meds
4. Medication safety
5. Follow the policies and procedures of your agency, and maintain maternal and fetal monitoring, even when decision made to go for c-section
Labor induction (Olds, Chapter 27). Use of oxytocin to induce
uterine contractions before their spontaneous onset
Use of Bishop Score to evaluate for
likely success of induction (a 13-point scale, with 9 or greater for primips and 5 or greater for multips); see Olds, Table 27-3
Cervical ripening with chemical agents, like:
(prostaglandin E2 gel – Cervidil) or
mechanical agents (laminaria) – administered by MD
Amniotomy – AROM
what is it for?
often used with what meds?
done with?
assess for what?
--Can induce labor when cervix is ripe or augment labor if progress slows.
--Often used with oxytocin induction (more effective than either method alone).
--Painless; done with Amnihook; amniotic fluid allowed to drain slowly.
--Assess FHR immediately before and after AROM (transient tachycardia is common, but bradycardia and variable decels are not)
Forceps-assisted birth and conditions required for use?
Used much less frequently than in the past.
Certain conditions required:
1. Cervix fully dilated
2. Bladder empty
3. Presenting part must be engaged (vertex is best)
4. Membranes ruptured
5. No CPD (cephalopelvic disproportion)
!!ASSESS FHR before and after application of the forceps!!
After birth with use of forceps, assess mother for: (3)
Vaginal and cervical lacerations (bleeding).
Urine retention.
Hematoma formation in pelvic soft tissues
After use of forceps in delivery, assess infant for: (3)
Bruising/abrasions at forceps site.
Facial palsy (pressure on CN VII).
Subdural hematoma
Vacuum-assisted birth
requires what before use?
how does it work?
Requires vertex presentation, ruptured membranes and no CPD.
Preferred over forceps.
Mother in lithotomy position, for best traction.
--Vacuum cup applied to fetal head (caput develops), and traction applied to facilitate descent of the head while mother pushes.
--Vacuum released and removed after birth of the head
Nurse’s role is support and education in vacuum (3)
1. Frequently assess FHR.
2. Observe newborn for trauma/infection at vacuum site; cerebral irritation (poor sucking or listlessness); cephalhematoma.
3. Reassure parents that caput will begin to disappear in a few hours.
Cesarean section delivery
Review information in Week 4 lecture notes
Post-term Pregnancy
defined as?
Defined as one that extends beyond the end of 42 weeks gestation
Post-term Pregnancy: Clinical manifestations: (4)
1. Maternal weight loss.
2. Decreased uterine size (from decrease of amniotic fluid).
3. Meconium in the amniotic fluid.
4. Advanced bone maturation of the fetus (very hard skull)
Post-term Pregnancy: Maternal risks
Associated with macrosomia and increased dysfunctional labor; induction and assisted delivery procedures more likely
Post-term Pregnancy: Fetal risks (5)
1. Macrosomia: prolonged labor, shoulder dystocia, birth trauma, asphyxia (reduced amount of O2)
2. Compromised placenta from “aging”. Placenta gradually decreases function after 37 weeks.
3. Amniotic fluid volume decreases to 800 mL at 40 weeks, and 400 mL at 42 weeks: increased risk of cord compression.
4. Fetal distress in labor from placental insufficiency.
5. Neonatal problems (e.g., meconium aspiration, RDS, hypoglycemia, asphyxia)
Why is Management is controversial
1. Some experts recommend induction at 41-42 weeks to reduce c-section rates and stillbirth or neonatal death.
2. Others will allow individual approach to 43 weeks, provided fetal well-being is normal
Nursing interventions: Postterm (4)
1. Antepartum assessments once or twice weekly, daily fetal movement monitoring.
2. Monitoring in labor.
3. Careful assessment of FHR and pattern, pH for acidosis.
4. May need amnioinfusion
OBSTETRIC EMERGENCIES: Shoulder Dystocia
The head is born but the shoulder cannot pass under the pubic arch
Sx of shoulder dystocia (4)
Symptoms may include:
1. labor progress that slows markedly,
2. a caput forming that is increasing in size;
3. as head emerges it retracts against the perineum or
4. external rotation does not occur
Potential injuries to fetus include (3)
asphyxia, brachial plexus damage and fracture (humerus or clavicle)
Mother’s risk of shoulder dystocia is (1)
excessive blood loss from uterine atony or rupture, and lacerations.
Nursing interventions for shoulder dystocia (4)
1. Assist to position woman on hands and knees, or lateral recumbent, to help reposition the fetus.
2. AVOID FUNDAL PRESSURE!!
3. May be called to assist in applying suprapubic pressure – be certain to document appropriately.
3. Assess newborn for fracture of clavicle or humerus, as well as brachial plexus injuries or asphyxia.
4. Assess woman for risk of uterine rupture (excessive bleeding, hemorrhagic shock with firm uterus).
OBSTETRIC EMERGENCIES: Uterine rupture
May be small, and managed with laparotomy, repair of laceration and blood transfusions as needed.
If severe, hysterectomy and blood replacement needed
Nursing interventions uterine rupture (4)
1. IV fluids; administer blood products as needed
2. Oxygen
3. Prep for immediate surgery
4. Provide support and encouragement to family

**Fetal mortality 50-75%; maternal mortality may be high if not treated immediately**
Prolapsed Umbilical Cord (3 s/s)
1. Fetal bradycardia with variable decels
2. Woman may report feeling the cord after ROM
3. Cord is seen or felt in or protruding from vagina
Nursing Interventions Prolapsed Umbilical Cord (3)
1. CALL FOR ASSISTANCE!!
2. Glove the examining hand quickly, and insert two fingers into the vagina to the cervix– with fingers on either side of the cord or both to one side, exert upward pressure against presenting part, to keep pressure off the cord.
3. Put woman into EXTREME TRENDELENBURG or knee-chest
If cord is protruding from vagina
wrap in sterile towel saturated with warm sterile normal saline
Nursing Interventions Prolapsed Umbilical Cord protuding from vagina (5)
1. Administer oxygen at 8-10 L/min until birth accomplished.
2. Start IV fluids
3. Continue to monitor FHR and pattern, if possible by scalp electrode
4. Provide explanations to woman and partner
5. Prepare for immediate vaginal birth (if fully dilated) or for c-section.

can be scary and exciting....variable decels is the key!!
Amniotic Fluid Embolism
Occurs when amniotic fluid containing debris (e.g., vernix, hair, skin cells or meconium) enters maternal circulation, causing pulmonary obstruction, leading to respiratory distress and circulatory collapse
Amniotic Fluid Embolism can occur when?
Can occur whenever the amniotic sac is open, and enough pressure exists to force fluid into maternal veins (especially if uterine laceration or rupture)
amnoiotic fluid embolism risk for fatality increase with?
Although uncommon, it causes about 10% of maternal deaths in U.S. – fetal mortality rate as high as 50%
Amniotic Fluid Embolism can lead to what conditions?
Can lead to DIC (Disseminated intravascular coagulation) and other coagulation problems; pulmonary HTN and left ventricular failure
Risk factors for AFE include
1. multiparity,
2. rapid labor,
3. abruption,
4. oxytocin induction;

fetal factors include:
1. macrosomia,
2. death,
3. meconium passage
Nursing interventions AFE (5)
1. Observe for respiratory distress, circulatory collapse and hemorrhage
2. Oxygenate with face mask or resuscitation bag delivering 100% oxygen and prepare for intubation
3. Assist with CPR (tilt pregnant woman 30 degrees to the side to displace the uterus)
4. Maintain cardiac output with IV fluids; administer blood; insert Foley catheter and monitor urinary output
5. Monitor maternal and fetal status; prepare for emergency birth

**If she survives, will be moved to critical care for monitoring and blood replacement, coagulopathy treatment**
What is the leading cause of maternal morbidity and mortality?
Postpartum Hemorrhage, when is it classifed?
Classified as early (in first 24 hours) or late (between 24 hours and 6 weeks)
Risk factors for postaprtum hemorrhage (11)
1. Uterine atony (overdistended uterus, anesthesia, previous history of uterine atony, prolonged labor, trauma during assisted delivery procedures)
2. Lacerations of birth canal
3. Retained placental fragments
4. Ruptured uterus or inversion of uterus
5. Placenta accreta (deep attachement of the placenta)
6. Coagulation disorders
7. Placenta previa or abruptio
8. Manual removal of placenta
9. Magnesium sulfate in labor or postpartum
10. Endometritis
11. Uterine subinvolution
Nursing Interventions for postpartum hemorrage (6)
1. Assess vital signs and maternal condition, especially inspect the perineum
2. Assess uterine fundus, which should be firm and at level of umbilicus
3. Assess for bladder distention, which can prevent proper uterine contraction
4. If uterus is hypotonic, provide firm massage to fundus, expel clots from the uterus, and administer oxytocin infusions as ordered
**See Olds, Table 38-1, for uterine stimulant drugs used to manage postpartum hemorrhage and the appropriate nursing interventions (Table 37-1 in 7th ed.)
5. Assist with laceration repair, or possible surgical interventions as needed
6. Provide calm explanations to woman and her family about the interventions and the need to act quickly **See Olds, Nursing Care Management text section for Postpartum Hemorrhage.
Postpartum Infection
Defined as any clinical infection of the genital tract which occurs within 28 days of childbirth, miscarriage or induced abortion
Postpartum Infection signs
Presence of fever of 38°C or more on 2 consecutive days in first 10 postpartum days after first 24 hours
Postpartum Infection rate
The major cause of worldwide maternal morbidity and mortality; in U.S. accounts for about 6%. More common after c-section births
Common postpartum infections: (5)
1. Endometritis
2. Wound infection
3. Mastitis
4. UTI’s
5. Respiratory tract infections.
Most effective and least expensive treatment for postpartum infection is:
prevention
ways to prevent infection (3)
1. Good maternal nutrition status
2. Perineal hygiene and good handwashing
3. Strict adherence to aseptic technique during childbirth and postpartum.
Management of endometritis (3)
1. IV broad-spectrum antibiotics.
2. Supportive care (rest, hydration, pain relief)
3. Continue assessment of lochia, vital signs and changes in condition
Discharge teaching for infection (4)
1. Hygiene
2. Signs and symptoms of infection
3. Wound care
4. Follow-up by home care nurses can be beneficial for woman at high risk.