High Risk Delivery (skeleton notes)

Why is external version perfomed at the hospital

In case it needs to become an emergecny c/section

If the non-stress test is non-reassuring, should an external version be performed?

No

Why is an external version not attempted before 37 weeks

High likelihood baby would not go back to abnormal presentation

What does a tocolytic medication do

Stops contractions by relaxing the uterus

What type of anesthesia might be given for pain control during the procedure

Epidural or spinal

An external version should NOT be performed if the woman is unlikely to deliver _________, Which is the goal of the procedure

Vaginally

Another contradictions for external version is

Previous c/section or other significant uterine surgery and uteroplacnetal insufficency 

If compromise occurs during an external version, a _______may be necessary

C/section

T/F: There is always a chance that the fetus could return to an abnormal presentation after a successful external version

True

Induction and augmentation of labor are artifical methods used to ______ contractions

Stimulate

Induction

Inhitiating labor before sponatnous onset

Augmentation

Labor has already spontanously started: however, progress is inadequate

Elective inductions are performed at the convience of the provider/patient. Elective inductions can be scheduled as early as ____ weeks; however, recommendations suggest waiting until ____ weeks.

• 39 weeks

• 40 weeks

Inductions are associated with a higher c/section birth rate. This increased risk can be mitigated if the cervix is already dilated (at least ____ cm) and somewhat effaced - “favorable cervix.”

2

What scoring system can be used for elective inductions to determine whether or not the cervix is favorable?

Bishop Score

Bishop Score

Used to estimate how easily a woman’s labor can be induced. Higher scores are associated with a greater
likelihood of successful induction because the cervix has undergone prelabor changes, ‘ripening.’

A vaginal birth is more likely to result if the Bishop Score is higher than ____

8

T/F: Any contraindication to labor and vaginal birth is a contraindication to induction or augmentation of labor

True

Contraindictions of induction and augmentation of labor

• Placenta previa

• Vasa previa

• Umbilical cord prolapse

• Abnormal fetal presentation

• Active genital herpes

• Previous uterine surgery (classical cesarean

Classic incision

The mother can never deliver vaginally and just is a repeat c/scetion

Low-transvere incision

The mother can be a candidate of vaginal delivery again

What is the main risk for induction and augmentation of labor

Hypertonic Uterine activity (too many contractions in a short amount of time)

What effect does hypertonic (excessive) uterine activity have on the fetus?

Reduce perfusion to the placenta and reduce fetal oxygenation

Cervical ripening

Used to ripen (soften) the cervix

Prostaglandin Gel (Dinoprostone {Prepidil}):

Applied to the vagina/cervix, and repeated every 6-12 hours as needed

Vaginal insert (Dinoprostone {cervidil}:

Looks like tampon and sits in for 12 hours and then is removed

A vaginal insert can be removed if mom experiences 

Tachystsyole

Misoprostol (cytotec):

Tiny pill that can be given orally or vaginally. 25mcg and repated every 3-6 hours PRN

For vaginal insertions, the patient should remain recumbent for at least _______minutes

30

What is the expected/therapeutic response of the cervical ripening medications discussed on the previous page(Cytotec, Cervidil, etc.)?

Softening of the cervix and effacement

What is the major adverse effect associated with cervical ripening agents?

Tachysystole

Should patients be on CONTINUOUS monitoring if their labor is being induced/augmented with a cervical ripening agent? (YES/NO)

Yes

Which cervical ripening agent CAN be removed?

Vaginal insert (cervidil)

Which cervical ripening agents CANNOT be removed?

Misoprostol and prepidil

Mechanical methods used for induction/augmentation (DECREASE/INCREASE) the risk for excessive uterine activity.

decrease

Membrane striping is the digital seperation of the ______ membrane from the wall of the ______ and lower uterine segment

• Amnitoic

• Cervix

When membrane stripping is performed, spontaneous labor usually occurs within______hours and reduces the need for other induction methods.

 

48

Most common medciation gievn for induction and augmentation of labor is

Oxytocin

Oxytocin is started slowly ____ to ____ milli-units/min

0.5 to 2 

Oxytocin is increased gradually as needed ( 1-2 milli-units/min increments every ___ min)

30

Once active labor is achieved and/or an adequate contraction pattern exists, the Oxytocin rate can

remain where it is at or can be reduced in similar increments

Once we receive an order for Oxytocin from the physician, the _____ decides when to start, titrate, and stop the Oxytocin the infusion using the facility’s protocols and medical orders.

nurse

All decisions with oxytocin are made in regard to the _____________

_____________ _____________pattern and  _______ pattern.

fetal heart rate and contraction

TRUE OR FALSE: A patient receiving Oxytocin will be on continuous monitoring

True

Prior to Oxytocin administration, the FHR/contraction pattern will be assessed for a minimum of 20 minutes to determine baseline and fetal well-being. A vaginal exam willalso be performed to determine cervical  ______and verify ______presentation.

dilation and cephalic 

Based on the statement above, when should the nurse NOT start Oxytocin?

If Fetal HR is abnormal or can’t determine the FHR

Tachysystole may reduce placental blood flow (uteroplacental insufficiency), which __________the exchange of fetal oxygen. 

Decreases

The _____decides when to titrate and stop oxytocin the infusion based on what he/she observes on the fetal monitoring strip.

Nurse

In what instance might a vaccum or forceps be used during delivery

• Shorten the second stage of labor (pushing stage)

• Fetal indications

Maternal risk for operative vaginal delivery is 

Laceration and hemotoma of the vagina

Infant risk for operative vaginal delivery: what is Ecchymosis

Bruising

Infant Risk for operative vaginal delivery: Cephalohematoma is an accumulation of blood under the scalpe. This generally does not pose a major risk and resolves in ___to ____weeks.

2 to 3 weeks

Infant risk for vaginal operative derlivery: Subgaleal hemorrhage: unlike a cephalohematoma, this can be massive, leading to profound___________________ shock.

Hypovolemic shock

Membranes must be ______________ and the patient must be ______________ dilated/effaced (10cm/100%) for forceps or a vacuum to be used.

Ruptured and completely

For a vacuum delivery, no more than _____ pop-offs are allowed and it cannot be followed by an attempt to deliver with __________

3 and forceps

Episiotomy 

incision of the perineum just before birth

If you have a patient who is 10cm dilated/100% effected, but the fetus is still at a high station, allow the woman to __________to prevent an episiotomy.

labor down

How can a woman care for an episiotomy site postpartum?

Ice packs

Why has the number of c/section births risen over the past decades?

Advanced maternal age

C/sections are performed when awaiting ___________birth would compromise the mother, fetus, or both.

Vaginal

C/section maternal risks

• Infection

• Hemorrhage

• Urinary tract trauma
  or infection

• Thrombophlebitis or
  thromboembolism

• Paralytic ileus

• Atelectasis

• Anesthesia
  complications

C/section infant risks

• Inadvertent preterm birth

• Transient tachypnea

• Persistent pulmonary hypertension of the
  newborn

• Traumatic injury

What is the greatest risk of the fetus is delivered preterm

Lung immaturity

Transient Tachypnea is caused by _______absorption of the lung fluid

delayed

What labs are drawn prior to the c/section?

CBC and blood type

what are given to reduce gastric acidity prior to the c/section.

Famotidine(Pepcid)or Sodium Citrate with Citric Acid (Bicitra)

A single dose of prophylactic antibiotic such as Ampicillin or Cephalosporin are given prior to the c/section or during surgery. Additional antibiotic doses are also given for _____hours post-op

24

What form of anesthesia can be used for a c/section?

Spinal anestetic

T/F: A wedge should always be placed under one hip while the monther is on the operating table

TRUE

Why is a wegde always placed under one hip while the mother is on the operating table

The supine position compressing the mothers inferior vena cava, which leads to a reduction in maternal cardiac output and decreases placental perfusion

When should a foley catheter be placed? Why is a Foley catheter placed during a c/section?

After her regionall block is established and allows the nurse to record I/O and keeps the bladder empty/away from the operating site

SCD’s are placed on paitenst undergoing a c/section due to the risk of

Thromboembolism

The uterine incision may not always match the______incision!

Skin

Low Transvere incision

Most common and preferred because it has a low risk for rupturing during a subsequent birth

Low vertical Incision

Can be extended upward to make a larger incision if needed

Classical incision

Vertical incision into the upper uterus. May be the only choice if low transverse and low vertical do not work

Normal labor =

progression of cervical effacement, dilation, and fetal descent

Dysfunctional Labor =

Labor that does not result in normal progress

 

What type of birth might be needed if dysfunctional labor does not resolve or if compromise occurs within the fetus or mother?

Operative birth

The two patterns of ineffective contractions are

Labor dystocia and tachysystole

Labor dystocia means difficult labor. It is often used to describe a labor that does not progress as expected. This is also termed: ________ to _______

Faliure to progress

Labor dystocia typically occurs during which PHASE in the 1st stage of labor

Active

 

The management of labor dystocia depends on the cause. What are some possible interventions that may be performed?

-        Getting an order from the physician to start oxytocin

-        The provider can come break the water

-        Position changes

-        Getting mom proper pain management

Tachysystole can be spontaneous or _____

induced

The management of tachysystole depends on the cause. What are some possible interventions that may be performed? 

• Stop the oxytocin/decrease the rate

• administer tocolytics

In tachysystole: more than ____contractions in _____ minutes, averaged over 30 minutes

5 in 10min

In tachysystole: contrctions lasting _ mins or longer can be a sign

2

In tachysystole: Contractions with less than _ min of resting time between can be a sign

1

In tachysystole: another sign is faliure of the uterus to return to _____ _____ between contractions

Resting tone

Fetal macrosomia is

baby that weights more than 8lbs, 13oz or 4,000g

Size is relative” means that a woman with a small or _______shaped pelvis may not be able to deliver a normally sized infant.

abnormally

Labor is longer and more uncomfortable when the fetus is in what position?

OP

 

What intervention can help promote the fetal head to rotate into the OA (occiput anterior) position?

• Hands and knees position

• Turn side lying and use a peanut ball

• squatting

Why could a multifetal pregnancy result in dysfunctional labor?

The uterus is overdistended

When is a shoulder dystocia more likely to occur

When the fetus is large

After delivery, what should be assessed?

Clavicals for deformities or bruising

What type of pelvis could hinder labor and/or obstruct fetal passage

Small or abnormaly shaped

What is the most common soft tissue obstruction

Full bladder

Why are infections more likely if the mother and fetus membranes have been ruptured for a prolonged period of time

Oragnisms can ascend from the vagina

Do precipitous labor begin abruptly or gradually

Abruptly