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39 Cards in this Set

  • Front
  • Back
What is an external version?
Procedure in which the fetus is changed from a breech to a cephalic presentation by external manipulation of the maternal abdomen.
What are the criteria for external version?
* The pregnancy is 36 or more weeks’ gestation
* A reactive nonstress test (NST)-obtained immediately prior to performing the version
* The fetal breech is not engaged
Before the external version is begun, an ultrasound is used to locate the placenta and to confirm fetal presentation.
What are the contraindications?
* Maternal problems (uterine anomalies, uncontrolled preeclampsia, or third-trimester bleeding).
* Complications of pregnancy (rupture of membranes (ROM), oligohydramnios, hydramnios, or placenta previa).
* Previous cesarean birth or other significant uterine surgery.
* Multiple gestation
* Nonreassuring fetal heart rate or other evidence of uteroplacental insufficiency
* Fetal abnormalities (intrauterine growth restriction (IUGR) or nuchal cord)
What are the nurse’s responsibilities during a version?
* Give terbutaline subcutaneously to relax the uterus per orders
* Maternal vital signs
* Reactive NST
* Fetal monitoring with electronic fetal monitoring (EFM), ultrasound, or both

The version is discontinued in the presence of severe maternal pain or significant fetal bradycardia or decelerations.
What is an amniotomy?
The artificial rupture of the amniotic membranes (AROM) using an instrument called an amnihook.
* At least 2 cm of cervical dilatation is required
* May be performed in hope of starting (inducing) labor
* May be used during the first stage to augment labor (accelerate the progress)
* Amniotomy manipulates both hormones and mechanical factors to stimulate labor
- natural prostaglandins are released which stimulate uterine contractions
-escape of amniotic fluid allows the presenting part to descend and place direct pressure on the cervix
What is the nurse’s role during an amniotomy?
* Explains the AROM procedure
* Assesses fetal presentation, position, and station-amniotomy is usually delayed until engagement has occurred
* FHR is assessed prior and post procedure- marked changes, need to check for prolapse of the cord
* Amniotic fluid is inspected for amount, color, odor, and the presence of meconium or blood
* The number of vaginal exams must be kept to a minimum to reduce the chance of introducing an infection-there is now an open pathway for organisms to ascend into the uterus
* Monitor woman’s temperature a minimum of every 2 hours
What are prostaglandins?
Prostaglandins are hormones. Prostaglandin agents have been demonstrated to cause cervical ripening, to shorten labor, and to lower requirements for Pitocin during labor induction.

Prepidil gel-contains 0.5 mg dinoprostone (prostaglandin E2 agent) and is placed intracervically
Cervidil-packaged as a 2 cm square vaginal insert and releases 10 mg of dinoprostone at a rate of 0.3 mg/hour over 12 hours
Misoprostol (Cytotec)-synthetic PGE1 analogue that is available as a tablet and inserted vaginally-one fourth tablet or 25 mcg should be initial dosage
What are the indications for use of prostaglandins?
Prostaglandins are used in labor induction that is indicated but not emergent-maternal gestational diabetes, postdates, or large-for-gestational-age fetuses.
What are the complications for use of prostaglandins?
Complications such as hyperstimulation and nonreassuring fetus status typically occur in the first hour after administration and peak at 4 hours.
What are the contraindications for the use of prostaglandins?
Contraindications for Prepidil include:
* Client with known sensitivity to prostaglandins
* Presence of nonreassuring fetal status
* Unexplained bleeding during pregnancy
* Strong suspicion of cephalopelvic disproportion
* Client already receiving Pitocin
* Client with 6 or more previous term pregnancies
* Client who is not anticipated to give birth vaginally

Contraindications for Cytotec include:
* Presence of uterine contractions three times in 10 minutes
* Significant maternal asthma
* History of previous cesarean birth or other uterine scar
* Bleeding during the pregnancy
* Presence of placenta previa
* Nonreassuring FHR tracing
What is the nurse’s role during the administration of prostaglandins?
* Information about procedure
* Answer questions
* Baseline maternal vital signs
* Electronic fetal monitoring
* Positioning-lie supine with a right hip wedge for specified time
* Assess for side effects for at least 2 hours following insertion

During administration of PGE2, if nausea and vomiting are present or contractions occur more frequently than every 2 minutes (and/or last >75 seconds), the gel is removed.
What is the induction of labor?
The stimulation of uterine contractions before the spontaneous onset of labor, with or without ruptured fetal membranes, for the purpose of accomplishing birth.
What are the indications for induction?
* Diabetes mellitus
* Renal disease
* Preeclampsia
* Premature rupture of membranes (PROM)
* History of rapid labor (precipitous labor and birth)
* Chorioamnionitis
* Postterm gestation
* Mild abruptio placentae without evidence of nonreassuring fetal status
* Intrauterine fetal demise (IUFD)
* Intrauterine fetal growth restriction (IUGR)
* Alloimmunization
What are the contraindications?
All contraindications to spontaneous labor and vaginal birth are contraindications to the induction of labor.

Other contraindications include:
* Client refusal
* Placenta previa or vasa previa
* Transverse fetal lie
* Prior classic uterine incision (vertical incision in the upper portion of the uterus)
* Active genital herpes infection
* Some instances of positive maternal human immunodeficiency virus (HIV) status
* Fetal immaturity
* Cervical changes favorable for induction have not occurred
What is a Bishop’s score?
A prelabor scoring system that is helpful in predicting the potential success of induction.
The higher the total score for all the criteria, the more likely it is that labor will occur.
How is labor induced?
When the cervix is favorable, amniotomy, stripping of the amniotic membranes, intravenous Pitocin infusion, and complementary methods (sexual intercourse; self or partner nipple or breast stimulation; use of herbs, castor oil, or enemas; acupuncture; and mechanical dilatation of the cervix with balloon catheters) are the most frequently used methods of induction.
How does the nurse instruct the client?
Client teaching should include the purpose of induction, the procedure itself, nursing care that will be provided, assessments, comfort measures, and a review of breathing techniques that may be used during labor.
What is Pitocin?
Oxytocin (Pitocin) exerts a selective stimulatory effect on the smooth muscle of the uterus and blood vessels. Pitocin affects the myometrial cells of the uterus by increasing the excitability of the muscle cell, increasing the strength of the muscle contraction, and supporting propagation of the contraction (movement of the contraction from one myometrial cell to the next).
What contraindicates use of Pitocin?
Contraindications of using Pitocin include:
* severe preeclampsia-eclampsia
* cephalopelvic disproportion
* malpresentation or malposition of the fetus, cord prolapse
* preterm infant
* rigid, unripe cervix; total placenta previa
* presence of nonreassuring fetal status
What are the nursing responsibilities during induction?
Nursing responsibilities during induction include:
* explain induction or augmentation procedure to client
* apply fetal monitor, and obtain 15- to 20-minute tracing and nonstress test (NST) to test FHR before starting IV Pitocin
* start with a primary IV, and piggyback secondary IV with Pitocin and infusion pump
* ensure continuous monitoring of the fetus and uterine contractions
* maximum rate is 40 milliunit/min. (maximum dose is generally between 16 and 40 milliunit/min.)
* assess FHR, maternal BP, pulse, frequency and duration of uterine contractions, and uterine resting tone before each increase in the Pitocin infusion rate
* record all assessments and IV rate on monitor strip and on client’s chart
* record on monitor strip all client activities, procedures done, and administration of analgesic agents to allow for interpretation and evaluation of tracing
* assess cervical dilatation as needed
* apply nursing comfort measures
* maintain intake and output record
* discontinue IV Pitocin infusion and infuse primary solution when (1) nonreassuring fetal status is noted; (2) uterine contractions are more frequent than every 2 minutes; (3) duration of contractions exceeds more than 60 seconds; or (4) insufficient relaxation of the uterus between contractions or a steady increase in resting tone are noted. In addition to discontinuing IV Pitocin infusion, turn client to side, and if nonreassuring fetal status is present, administer oxygen by tight face mask at 7-10 L/min; notify physician/CNM.
What are the complications of oxytocin use?
* hyperstimulation of the uterus, resulting in uterine contractions that are too frequent or too intense, with an increased resting tone
* hypertonic contractions, may lead to decreased placental perfusion and nonreassuring fetal status
* uterine rupture
* water intoxication (nausea, vomiting, hypotension, tachycardia, cardiac arrhythmia)
What measures may be implemented to reverse hyperstimulation?
Discontinue IV Pitocin, turn client to side, and if nonreassuring fetal status is present, administer oxygen by tight face mask at 7-10 L/min; notify physician/CNM.
What is amnioinfusion? What are the indications for amnioinfusion?
Amnioinfusion (AI) is a technique by which warmed, sterile normal saline or Ringer’s lactate solution is introduced into the uterus through an intrauterine pressure catheter (IUPC).

AI can be used intrapartally to increase the volume of fluid in cases of oligohydramnios, in which cord compression causes FHR deceleration and nonreassuring fetal status. AI is also implemented to dilute moderate to heavy meconium released in utero and for preterm labor with premature rupture of membranes.
What is the nurse’s role during amnioinfusion?
* helps administer the AI
* assesses the woman’s vital signs and contraction status
* monitors the FHR by continuous EFM
* provide ongoing information to the laboring woman and partner
* comfort measures and positioning are vital (woman is now on bed rest)
* evaluation of fluid expulsion (counting sanitary pads and visual observation during perineal care)
What is an episiotomy?
An episiotomy is a surgical incision of the perineal body to enlarge the outlet.
* two types of episiotomy in current practice are midline and mediolateral
What controversies address the use of episiotomy?
Research suggests that (1) rather than protecting the perineum from lacerations, the presence of an episiotomy makes it more likely that the woman will have deep perineal tears and (2) perineal lacerations heal more quickly than deep perineal tears. Incidence of major perineal trauma (extension to or through the anal sphincter) is more likely to happen if a midline episiotomy is done and that a repeat of the trauma is likely to occur with subsequent births.
What factors may lead to episiotomy?
* primigravid status
* large or macrosomic fetus
* occiput-posterior position
* use of forceps or vacuum extractor
* shoulder dystocia
* use of lithotomy and other recumbent positions (causes excessive and uneven stretching of the perineum)
* encouraging or requiring sustained breath holding during second-stage pushing
* arbitrary time limit placed by physician/CNM on the length of the second stage
What might a patient do to prevent the need for an episiotomy?
* Kegel exercises throughout pregnancy to improve vaginal tone
* Perineal massage during pregnancy
* Natural pushing during labor, and avoiding the lithotomy position or pulling back on legs (which tightens the perineum)
* Side-lying position for pushing, which helps slow birth and diminish tears
* Warm or hot compresses on the perineum and firm counterpressure
* Encouraging a gradual expulsion of the infant at the time of birth by encouraging the mother to “push, take a breath, push, take a breath” thereby easing the infant out slowly
What nursing care is implemented following an episiotomy?
* supportive care-placing a hand on her shoulder and talking with her can provide comfort and distraction from the repair process
* comfort measures-application of an ice pack to the perineum
* inspect episiotomy site every 15 minutes during the first hour after the birth for redness, swelling, tenderness, bruising, and hematomas
* pain management
* nursing advocacy is needed to promote selective rather than routine episiotomy
What are forcep deliveries?
Forceps are surgical instruments designed to assist in the birth of the fetus by providing either traction or the means to rotate the fetal head to an occiput-anterior position.
What is a vacuum assisted delivery?
A vacuum-assisted birth is an obstetric procedure used to facilitate the birth of a fetus by applying suction to the fetal head. The suction cup is placed against the fetal occiput, and the pump is used to create negative pressure (suction) inside the cup. Traction is applied in coordination with uterine contractions, descent occurs, and the fetal head is born.
What nursing care is associated with a vacuum assist?
* assess FHR by continuous EFM
* reassure parents that the caput (chignon) on the baby’s head will disappear within 2 to 3 days
* careful assessment of the infant’s skin color is needed, since infants born via vacuum are at increased risk for jaundice
What is a Cesarean Section?
Cesarean birth is the birth of the infant through an abdominal and uterine incision.
What are the medical indications for Cesarean Section?
* complete placenta previa
* cephalopelvic disproportion
* placental abruption
* active genital herpes
* umbilical cord prolapse
* failure to progress in labor
* nonreassuring fetal status
* previous classical incision on the uterus (either previous cesarean birth or myomectomy)
* benign and malignant tumors that obstruct the birth canal
* cervical cerclage
* breech presentation
* previous cesarean birth
* major congenital anomalies
* severe Rh alloimmunization
What factors are associated with increased maternal morbidity with CS?
* infection
* reaction to anesthesia
* blood clots
* bleeding problems

Women who have had a previous cesarean birth have an increased risk of bleeding problems in future pregnancies. There is also an increase in fetal demise and in neonatal respiratory distress and the need for oxygen administration in fetuses whose mothers have previously given birth via cesarean.
What nursing care measures are associated with Cesarean Section?
* preoperative teaching
* answer questions, explain procedures (IV, catheter, abdominal prep)
* antacids may be administered within 30 minutes of surgery (per orders)
* FHR with EFM
* vital signs
* ensures infant warmer is working, resuscitation equipment is available
* positioning (operating room table is adjusted so it slants slightly to one side or a hip wedge is placed under the right hip to tip the uterus slightly and reduce compression of blood vessels)
* provide reassurance and describe procedures being performed to ease anxiety and to give the woman a sense of control
How is recovery from a CS different from vaginal birth?
* every effort should be made to assist the parents in bonding with their infant
* vital signs every 5 minutes until stable, then every 15 minutes for an hour, then every 30 minutes until she is discharged to the postpartum unit
* evaluates the dressing and perineal pad every 15 minutes for at least an hour
* monitor intake and output
* observe urine for bloody tinge, which could mean surgical trauma to the bladder
What is a VBAC?
VBAC is a vaginal birth after cesarean.

The following aspects need to be considered for VBAC:
* a woman with one previous cesarean birth and a low transverse uterine incision may be counseled and encouraged to attempt a VBAC
* a clinically adequate pelvis is a requirement for VBAC
* A woman with two previous cesareans who has also had a previous vaginal birth may attempt VBAC
* It must be possible to perform a cesarean within 30 minutes
* a physician, adequate staff, anesthesia, and facilities must be readily available throughout active labor to perform a cesarean birth if needed
* A classic or T uterine incision is a contraindication to VBAC
What is the current practice?
Recent media reports identifying risks of VBAC have reintroduced the debate regarding its safety. Also, trends in counseling women to have an elective repeat cesarean birth are driving cesarean births to an all-time high in the United States.