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153 Cards in this Set

  • Front
  • Back
Define labor dystocia
long, difficult, or abnormal labor; not following "textbook"
What factors are associated with labor dystocia?
the 5 p's: passageway, passenger, position, powers , position, psychological
Example where passenger is cause of labor dystocia
fetal anomalies, malpresentation, CPD, suboptimal fetal position
Example where the passageway is the cause of labor dystocia
pelvic structure, soft tissue dystocia
Example where maternal position is cause of labor dystocia
supine
Example where psychological factors contribute to labor dystocia
anxiety and fear
Define "cleansing breath"
breath taken before bearing down to push in order to increase O2
Example where powers are cause of labor dystocia
ineffective uterine cx's
Some common problems associated with labor dystocia
pelvic structure, fetal causes, maternal position, psychological response, inadequate pain management/coping, inadequate uterine cx's
Risk factors that affect the "powers" associated with labor
body build, uterine abnormalities, malpresentations, cephalic-pelvic disproportion (CPD), overstimulation with pitocin, maternal fatigue, dehydration, fear, inappropriate timing of analgesics
Explain body build as a risk of labor dystocia
overweight by 30# or out of shape or short in stature
What is a hypertonic uterus
over-active tone, uterus is contracting too much
What pattern is observed with a hypertonic uterus
cx's are not coordinated with phase of labor
What phase of labor do we typically diagnose hypertonic uterus? Why?
latent phase when mom should be coping well but is not
Tx for hypertonic uterus
therapeutic rest
What is therapeutic rest
pain management, hot shower, rest
Which is the more common disorder r/t uterine tone?
hypotonic uterus
Define hypotonic uterus
decreased uterine tone
What is the problem with a hypotonic uterus
cx's are weak and ineffective; they aren't doing anything
What phase of labor is a uterus most commonly diagnosed as hypotonic
active phase
Upon palpation, if you are able to make an indent in the uterus during the active phase of labor, what does this suggest?
mild uterine tone, hypotonic uterus
Tx for hypotonic uterus
augment labor
What do you need to r/o before augmentation of labor
CPD
ROM and pitocin are used to do what, r/t labor dystocia?
induce or augment labor
What fetal presentation is considered an emergency
shoulder
Pelvic dystocia
contractures of pelvic diameter
Soft tissue dystocia
anatomic abnormality, full bladder or rectum,cervical edema
Can a fetus with breech presentation be delivered vaginally?
yes
What is a major risk with malpresentation
cord prolapse
What is the major problem with malpresentation and fetal tasks?
affects fetal ability to participate in cardinal movements and navigating through the birth canal
Examples of malpresentation
breech (complete, incomplete), face, shoulder
Complete Breech - lie, presenting part, reference point, attitude
vertical, breech, sacrum and feet, flexion
Percentage of births with breech malpresentation
3-4%
Examples of breech presentation
incomplete breech - frank, single foot; complete breech
Frank breech - lie, presenting part, reference point, attitude
vertical, incomplete breech, sacrum w/out feet, flexion except knees extended
Single foot breech - lie, presenting part, reference point, attitude
vertical, incomplete breech, sacrum, flexion except extension on one leg at hip and knee
What is external cephalic version (ECV)?
way of repositioning fetus in breeched position
What gestational age is ECV performed? Why?
36-37 wks; can induce delivery
What are the risks associated with ECV?
nuchal cord, fetal death, fetal distress, ROM, placental abruption, maternal/fetal
What factors does Friedman's Classification look at to monitor progress
cervical dilation, fetal descent, and parity
Define precipitous labor
<3hrs from onset of true labor
What doesn't happen during precipitous labor that leads to increased risk of complications?
not enough time to maneuver
What is one cause of precipitous labor
maternal cocaine use
Examples of complications associated with precipitous labor
subdural hematoma, lacerations, uterine rupture, amniotic fluid embolism, pph
If spontaneous active labor isn't progressing as expected, what methodology is often used?
reasonable period of time, typically 4-6h, is allowed to determine safety
What might interrupt this reasonable period of time?
suspected complications
What is meant by "trial of labor"
if labor isn't progressing as expected, we allow 4-6hrs to pass to determine the safety of the delivery
During a "trial of labor" what factors are assessed to determine safety of the delivery
maternal pelvis is questionable size/shape, vaginal birth after c/s, abnormal presentation
Define induction of labor (IOL)
initiate cx's before spontaneous onset w/ pitocin or amniotomy
What methods are used to induce/augment labor
pitocin, amniotomy
What determines how successful IOL is?
how favorable the cervix is
Define "favorable cervix"
how ripe the cervix is; how soft it is for stretching
Vaginal births are associated with what kind of cervix
favorable cervix
Define "Bishop Scoring"
method of evaluating how favorable/inducible the cervix is
The higher the Bishop Score/ the lower the Bishop score
the more inducible the cervix is; to more likely induction will be unsuccessful and result w/ a c/s
What measurement is used to determine how inducible the cervix is?
Bishop Scoring
Describe the changes the cervix experiences as it becomes more favorable
firm to soft, posterior to anterior
What Bishop Score is considered appropriate for a nullparous woman? Multiparous woman?
>9, >5
If it is deemed necessary to induce labor but the cervix has a low Bishop Score, what intervention is necessary?
administer chemical agents to ripen the cervix
High success rate of induction, lower doses of pitocin, and quicker progression are associated with what?
ripe cervix
What chemical agents are administered to ripen the cervix
prostaglandins, misoprostal
Describe the dosage of pitocin associated with IOL
1 milliunit q15-20m until adequate contractions are achieved
What assessment is also necessary to perform with careful administration of pitocin to augment labor?
monitor FHR q15m/ between cx's
Indications for IOL
suspected fetal jeopardy, PROM, post term, chorioamnionitis, maternal medical problems, pregnancy induced HTN, FD
Why might you want to induce labor with FD?
don't want to put mom at risk, helps with grieving process
Fetal distress, failed induction, uterine rupture, water intoxication and hyper-stimulation are all considered what?
risks of IOL
What defines hyper-stimulation with pitocin
very frequent and intense cx's with non-reassuring FHR
What is the uterine resting tone associated with hyper-stimulation with pitocin? Its significance?
20mmhg; the uterus is not resting and vulnerable to rupture
The resting time between contractions is radically decreased with hyper stimulation with pitocin. Why is this a concern?
decrease O2 perfusion as mom bears down during contractions
If a pt is experiencing hyper-stimulation with pitocin what nursing invention is most important
turn off the pit
Why is turning off the pit the most important nursing intervention during hyper-stimulation w/ pitocin
it is the cause
Nursing management for hyper-stimulation w/ pitocin
turn of the pit, increase IV fluid, O2 via face mask, notify provider
Why do we want to increase IV fluid and administer O2 after turning off the pit during hypser-stimulation with pitocin
increase perfusion to fetus
What methods are used to augment labor
pitocin, amniotomy
What is the difference between IOL and Augmentation of labor?
spontaneous labor has already started but cx's have decreased with augmentation whereas induction of labor initiates the onset of spontaneous labor
What are the following signs associated with: pelvic pressure, low-dull back ache, menstrual-like cramping, change or increase in vaginal discharge, intestinal cramping (w/ or w/out diarrhea), and cx's < q10m
labor; pre-labor if <37wks
Generally speaking, what is the cause of PTL
unknown, multifactorial
What is a major culprit of PTL
infection
Why is infection a major culprit of PTL
fetus knows it is better to be out than in
What infections are associated with PTL
bacterial vaginosis, chlamydia, gonorrhea, UTI/pyelonephritis
What is the #1 infectious cause of PTL
BV
BV increases risk of PTL by what percentage
50%
infection, long-distance traveling, "on feet," stress (acute or chronic), poor nutrition, underweight, late or no prenatal care, lower SES or education, elicit drug use, and pre-exisiting or pregnancy complications are all associate with what?
risks of PTL
How is PTL diagnosed
documented uterine cx's, 80% effacement, dilation >1cm, <37wks
Biomedical markers, transvaginal u/s and home uterine activity monitoring are used to diagnose what?
PTL/PTB
What biomedical markers are tested with diagnosing PTL
salivary estriol, fetal fibronectin
Where is salivary estriol found
in mouth
Where is fetal fibronectin found
in vaginal canal
What predictive values do salivary estriol and fetal fibronectin have
high negative-predictive value, low positive-predictive value
Biomedical markers are best to determine who will/ who will not experience PTL
who will not
When do levels of salivary estriol increase
Prior to PTL
What is the accuracy of a swab positive for salivary estriol?
7-25%
What is the accuracy of a swab negative for salivary estriol
98%
A swab positive for salivary estriol is considered a ___________ ____________ predictor
poor-positive
When do levels of fetal fibronectin (FFN) normally appear during pregnancy?
early and late
What gestational age should we be concerned about if FFN is found positive in the canal?
24-34wks
What is the accuracy of positive FFN as an indicator of PTL
25-40%
What is the accuracy of negative FFN?
95%
What is the importance of negative findings of FFN and salivary estriol?
you are not at risk for PTL
What two steps are taken during the clinical management of PTL
tocolytic therapy and glucosteroids
What purpose does tocolytic therapy serve? Glucosteroids?
suppress uterine activity; promote development of lungs
General concern with tocolytic agents r/t ADE
CNS depressants
Therapeutic effect of Ritodrine and Terbutaline
relax smooth muscle
Magnesium sulfate
CNS depressant
Indomethacin
prostaglandin inhibitor
Nifedipine
calcium channel blocker
tachycardia, dysrhythmias, tremors/m. weakness, headache, N/V, hyperglycemia, pulmonary edema, mycoardial ischemia, hypotension, jitteriness and apprehension are all examples of what?
side effects of terbutaline
Examples of tocalytic agents
ritodrine, terbutaline, magnesium sulfate, indomethacin, nifedipine
SE od MgSO4
CNS depressant = decreased RR, absent or decreased DTRs, m. weakness, decreased urine output
What score would be appropriate for decreased DTRs
< 2+
How many cc's or urine is considered normal every hour? every 24hrs?
30cc's/hr, 500cc's/24hrs
After administering MgSO4 you notice the pt is very sleepy. What light bulb should go off?
change in LOC
Once noting a change in LOC or decreased RR of a pt taking MgSO4, what are some appropriate interventions
turn off the MgSO4, sternal chest rub, open main line to flush, administer O2, antedote
What is the antedote for MgSO4
calcium gluconate
MgSO4 has to be monitored very carefully. What are its therapeutic levels?
4-7, 4-8
Examples of nursing care necessary with administration of tocolytic agents
asess VS regularly, notify provider if HR>120, monitor urine output q1h, monitor ketonuria, assess for s&s's of pulmonary edema, limit fluid intake to 2500-3000cc's/day, position on l. lateral, provide pyschosocial support
S&S's of pulmonary edema
SOB, breath sounds are rhonchi or crackles
What purpose does the left lateral position serve
increased perfusion
Best place to listen for lung sounds
base of lungs, posteriorly
Why do we limit fluid intake with administration of tocolytic agents
decrease risk of pulmonary edema
What type of agents are Betamethasone and Dexamethasone?
glucosteroids
What purpose do Betamethasone and Dexamethasone serve
accelerate fetal lung maturity
General management considerations concerning tocolytic therapy
do not administer if it is best for the baby to come out
What dilation determines birth as inevitable
4cm
Early ROM
PROM, PPROM
PROM
early rupture of membranes at least 1h before onset of labor at any gestational age
PPROM
preterm pre-mature rupture of membranes <37wks GA
Percentage of PTLs that experience PPROM
25%
What is the goal of PPROM management
preventing PTL and maternal/fetal complications
What is expectant management? When do we use it?
observe and see what happens after PPROM
What testing is performed after PPROM? How often?
Biweekly BPP - U/S, NST and amniotic fluid measurements
What information does amniotic fluid measurements tell us? What is considered normal?
if amniotic fluid is decreasing; there is daily turnover of amniotic fluid, there shouldn't be too much or too little
Criteria for home care r/t PPROM and time
> 72hr
Criteria for home care r/t PPROM and cervical dilation
< 3cm
Criteria for home care r/t PPROM and sxs's
no sxs's of infection or PTL
Criteria for home care r/t PPROM and fetal presentation
no breech or transverse presentation
What self-assessments must be performed by the pt caring for herself at home after PPROM
T q4h (when awake), sxs's of infection, assess for uterine cx's, daily fetal movement counting
Activity modifications r/t PPROM and home care
modified bed rest, NPV, no baths, proper hygiene, antibiotics as prescribed
Complications of PPROM and PTL
infection, PTB, cord prolapse
Why is cord prolapse an associated complication of PPROM and PTL
if the baby is preterm, the head is smaller, leaving room for the cord to fall down alongside
Define chorioamnionitis
intraamnion infection with maternal-fetal risks
sxs's of chorioamnionitis
fetal tachycardia, elevated maternal temp, uterine tenderness, decreased cx's
What is the standard of care regarding chorioamnionitis and tocolytic therapy
tocolytic therapy is contraindicated
Risks associated with premature newborns
maintaining body temp, organ function, respiratory disorder syndrome (RDS)
What is L/S ratio?
Lecithin/sphingomyelin ratio
What assessment is the L/S ratio used for?
to check fetal lung maturity
What values of the L/S ratio suggest a newborn is at risk for RDS
< 2, < 3 (if diabetic)
Some terms used to describe different patterns of hours of labor
precipitous, multipara, nullipara, protracted active, secondary arrest, prolonged latent
protracted active labor
rate of dilation during active phase is below normal
secondary arrest r/t hours of labor
dilation stops > 2h during active phase
prolonged latent phase r/t hours of labor
nullipara > 20h, multipara > 14h
Based on Friedman's labor curve, how long should it take for a multiparous woman to FD
7-8h
Based on Friedman's Labor Curve, how long should it take for a nulliparous woman to FD
13-14h