Term
| What is the purpose of an amniotomy? |
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Definition
Induce or stimulate labor
To place internal electronic fetal monitoring |
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Term
| What is another name for amniotomy? |
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Definition
| Artificial Rupture of Membranes (AROM) |
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Term
| WHat is the technique for amniotomy? |
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Definition
Disposable plastic hook (Amnihook)-perforates the amniotic sac
Hook is presented through the cervix
The membranes are snagged
Hole is enlarged with the finger, allowing fluid to drain |
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Term
| Who is an amniotomy contraindicated in? |
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Definition
The presenting part of the baby is NOT ENGAGED in the pelvis -> cord can slip down between the head and the cervix…prolapsed cord
The cervix is less than 3 cm dilated
The presenting part is not cephalic |
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Term
| What are the 3 risks of an amnitomoy? |
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Definition
Prolapse of the cord
-Cord may slip down
-Cord can be compressed
Infection
-Interruption of the membrane barrier
-May cause chorioamnionitits
-Delivery within 24 hours of ROM is desirable
Abruptio Placentae
-If the uterus is distended when the membranes rupture. |
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Term
| What nursing considerations are taken prior, during and after an amniotomy? |
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Definition
-Baseline assessment-prior to procedure
-Assisting the MD or CNM during
-Care after the amniotomy:
+Assess for complications
+Note and chart amniotic fluid
+Assess temp q 2 hours after AROM
+Monitor for fetal tachycardia
+Change underpads frequently |
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Term
| What needs to be noted about fluid? |
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Definition
| COLOR (CLEAR), QUANTITY (USUALLY A MOD-LARGE AMOUNT, SCANT OR SMALL WOULD BE ABNORMAL), ODOR(NORMALLY DOESN’T HAVE A SMELL OR STRONG ODOR…MECONIUM) |
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Term
| What are the indications of induction? |
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Definition
ROM without labor onset (nearing that 24 hour period without onset of labor)
Post-term pregnancy
Fetal death
Chorioamnionitis
Maternal medical condition
What are some?
Maternal-fetal blood incompatibility |
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Term
| Who is induction contraindicated in? |
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Definition
Placenta previa
Vasa previa
Transverse fetal lie/Abnormal fetal presentation
Cord prolapse
Some uterine surgeries: classic C/S (vertical incision)
Maternal heart disease
Multifetal pregnancies: triplets or greater
Nonreassuring FHR patterns |
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Term
| What are the risks associated w/ induction? |
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Definition
Uterine HYPERstimulation
Uterine rupture
Maternal water intoxication
Oxytocin’s antidiuretic effects
Greater risk for C/S |
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Term
| What is the Bishop score? |
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Definition
| MD or CNM evaluates whether labor or birth are safer for the woman or fetus than continuing the pregnancy |
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Term
| What are the different bishop scores? |
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Definition
Higher scores are associated w/greater likelihood of successful induction.
Primigravida: 7 or higher
Multipara: 5 or higher
Similar to spontaneous birth: 8 or higher (ACOG, 1999) |
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Term
| What are the medical methods used to ripen the cervix? |
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Definition
Prostaglandin E2 (PGE2 , dinoprostone, Prepidil)
Cytotec (misoprostol) |
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Term
| What is the risk associated w/ cervical ripening? |
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Definition
| RISK OF HYPERSTIMULATION OF THE UTERUS |
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Term
| What are mechanical methods to cervical ripening? |
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Definition
| Hydrophilic inserts into cervical canal |
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Term
| What is the nursing care once the cervix has begun ripening? |
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Definition
| Continuous EFM prior to and after med is given |
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Term
| What needs to be assessed fetally when using pitocin? |
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Definition
Baseline fetal heart rate and patterns
Monitor for changes
Document FHR per policy |
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Term
| What needs to be assessed maternally when using pitocin? |
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Definition
Assess for adequate rest between UC’s
Monitor VS per policy
Intake and Output |
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Term
| What is the risk associated with the use of pitocin? |
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Definition
| UTERINE ATONY=RISK FOR HEMORRHAGE |
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Term
| What are the signs of hypertonic uterine activity? |
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Definition
Contraction longer than 90-120 seconds
Less than 30 seconds of relaxation between contractions
If IUPC:
Increased resting tone
Increased peak pressure of contraction
Increased Montevideo units
Fetal heart rate pattern of late decels |
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Term
| What are the nursing actions after hypertonic uterine activity is expected? |
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Definition
Reduce or stop oxytocin infusion
Reposition to side (either R or L)
Increase rate of primary nonadditive (mainline IV) infusion
Give oxygen by face mask at 8 to 10 ml/min
Notify physician or nurse-midwife |
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Term
| What are indications of external version? |
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Definition
Changing fetal position by external manual manipulation to CEPHALIC (Head first)
Used in Breech, Shoulder (transverse lie) |
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Term
| What are the indications of internal version? |
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Definition
Much less common
Used for vaginal birth of 2ND twin |
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Term
| Who is external version contraindicated in> |
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Definition
Uterine malformation
Previous vertical C/S incision
CPD (cephalopelvic disproportion)
Placenta previa
Multifetal gestation
Active labor
Oligohydramnios, ROM, Cord around fetal body or neck (NUCHAL CORD)
Uteroplacental insufficiency |
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Term
| What are the risks associated with external version? |
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Definition
Abruptio placentae
Cord compression
Nuchal cord
Maternal sensitization to fetal blood if mixed |
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Term
| What are the pre-version tests? |
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Definition
NST or BPP (Biophysical Profile)
Ultrasound |
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Term
| Why are pre-version tests done at 37 weeks +? |
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Definition
More likely to “hold” new position
Fetus may spontaneously turn close to term
If fetal compromise or onset of labor does occur during ECV, the fetus will be at or near term |
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Term
| Why are tocolytics and analgesics given prior to external version? |
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Definition
Tocolytic to relax the uterus while the version is being performed.
Analgesic: maternal comfort and relaxation: may help process if mom’s relaxed
*Labor induction may be done immediately after a successful version or the woman can await spontaneous labor |
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Term
| What are the nursing considerations pre and post external version? |
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Definition
PRE and POST procedure monitoring
VS, EFM, NST (Non-stress Test)
Assess for fetal distress and labor
MD explains the indications and risks
RN verifies her understanding of the purpose, risks, & limitations
Consent for C/S obtained and consent for external version
Explain purposes and side effects of any tocolytic drugs: Terbutaline
Emotional support to reduce anxiety
Give Rhogam if indicated |
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Term
| What is an operative vaginal birth? |
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Definition
When the MD applies traction to the fetal head during birth with a vacuum extractor or forceps
Used to shorten the second stage of labor to prevent fetal & maternal complications |
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Term
| What are Forceps or Vacuum Extraction: Indications? |
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Definition
Maternal exhaustion
Inability to PUSH effectively
Maternal cardiac or pulmonary disease
Cord compression
NON-REASSURING FHR patterns
Premature separation of the placenta:
If abruption occurs and fetus is engaged, the MD will attempt to deliver the infant ASAP |
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Term
| What are Forceps or Vacuum Extraction: Contraindications? |
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Definition
If maternal or fetal condition mandates a more rapid birth, a C/S should be done rather than forceps or vacuum extraction
Severe fetal compromise
HIGH fetal station
CPD (Cephalopelvic Disproportion) |
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Term
| What are Forceps or Vacuum Extraction: Risks? |
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Definition
Trauma to maternal or fetal tissues
Maternal:
Lacerations, hematomas (peri-urethral or 4th degree lacerations)
Large episiotomy
Infant:
Ecchymoses
Facial, scalp laceration
Facial nerve injury
Cephalohematoma & other intracranial hemorrhages
Chignon: circular scalp edema from vacuum |
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Term
| What are Forceps or Vacuum Extraction: Nursing Considerations? |
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Definition
Patient must be ROM and 10 cm dilated
Adequate analgesia
BLADDER emptied via catheter…why?
Continually ASSESS FHT
Prepare equip and assist MD as needed
Emotional support; provide info to patient and family
Post-delivery:
Observe mom for trauma, ice/cold packs
Observe infant for lacerations, bruising, facial asymmetry, seizures & explain to parents |
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Term
| What does a seizure after vacuum extraction indicate? |
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Definition
| INTRACRANIAL HEMORRHAGE or neonatal hypoglycemia or sepsis. |
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Term
| What is Outlet operative? |
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Definition
| fetal head is on the perineum w/scalp visible |
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Term
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Definition
| leading edge of fetal skull is at station +2 |
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Term
| What is Midpelvis operative? |
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Definition
| leading edge of fetal skull is between 0 and +2 |
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Term
| What is the vacuum technique? |
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Definition
Hand pump creates suction to hold the vacuum cup on the fetal head in the midline occiput.
MD applies intermittent traction w/UCs & pushing
Hospital policy limits # of times vacuum can be applied (usually 3 |
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Term
| What is the nursing care after vacuum extraction? |
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Definition
Empty the bladder, assess maternal vital signs and monitor through out the procedure, monitor fetal response to the procedure.
Post partum: assess the mother and the infant for trauma or bruising. Monitor mother for ability to urinate normally following the procedure. |
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Term
| What are the indications for an episiomotomy? |
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Definition
Fetal shoulder dystocia
Vaginal breech birth
Forceps or Vacuum assisted birth
OP position (face up)
Obvious risk for serious tears of the soft tissues of the genital tract exists |
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Term
| What are the episiomoty risks? |
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Definition
Infection
Perineal pain
↑ blood loss
Associated w/poor sexual satisfaction and comfort 3 months after birth…
No guarantee she won’t tear in addition to episiotomy |
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Term
| What are the advantages to an midline episiotomy? |
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Definition
Minimal blood loss
Better healing
Less pain than Mediolateral |
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Term
| What are the disadvantages of an midline episiomoty? |
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Definition
Laceration may extend to ANUS
Less enlargement than medioateral |
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Term
| What are the disadvantages to mediolateral? |
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Definition
| dyspareunia: painful intercourse |
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Term
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Definition
| delaying pushing until the urge is felt: gradually distends the soft tissues of the pelvic floor. |
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Term
| What is Open glottis-technique vs. prolonged breath holding ? |
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Definition
| promotes gradual perineal stretching |
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Term
| What are the Episiotomy: Nursing Considerations? |
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Definition
| Observe for perineal hematoma, signs of infection, educate the mother on care of the incision, pain medications as needed. |
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Term
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Definition
1 or 2 previous low transverse incisions
No other uterine scars (fibroids) or uterine rupture
Adequate pelvis
MD & anesthesia available during labor |
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Term
| What are c-section indications? |
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Definition
Dystocia
CPD
HTN, preeclampsia, eclampsia
Maternal DM, heart disease, cervical cancer
Genital-HSV-Herpes Simplex virus
Previous uterine surgery ( C/S)
Persistent non-reassuring FHR patterns
Prolapsed cord
Fetal malpresentation Breech/transverse
Abruptio placentae, placenta previa |
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Term
| Who is C-section contraindicated in? |
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Definition
Infection
Hemorrhage
Urinary tract trauma
Thrombophlebitis, thromboembolism
Paralytic ileus
Atelectasis
Anesthesia complications
Death-increased if emergent |
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Term
| What are the fetal risks associated w/ c-section? |
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Definition
Inadvertent preterm birth
Transient tachypnea
Injury: laceration, bruising, fractures
Death due to infection, anesthesia, blood clots, bleeding problems |
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Term
| What is the prep for a c-section? |
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Definition
Pre-op labs:
CBC, H&H, Type & Screen
Type & Crossmatch if indicated
Anesthesia:
Usually epidural
General for emergency C/S
Pre-op meds:
Oral antacid: Pepcid or Bicitra po
Single dose antibiotic
Fetal monitoring:
Until just before sterile abdominal prep |
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Term
| What are the advantages of a vertical incision? |
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Definition
1) Quicker to perform
2) Better visualization of the uterus
3) Can quickly extend upward for greater visualization if needed
4) Often more appropriate for obese women |
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Term
| What are the disadvantages of a vertical incision? |
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Definition
1) Easily visible when healed
2) Greater chance of dehiscence and hernia formation |
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Term
| What are the advantages of a PFANNENSTIEL incision? |
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Definition
1) Less visibility when healed
2) less chance of dehiscence or formation of hernia |
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Term
| What are the disadvantages of a PFANNENSTIEL incision? |
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Definition
1) Less visualization of the uterus
2) Can’t be done as quickly
3) Can’t be easily extended to give greater operative exposure
4) Re-entry at a subsequent cesarean birth may require more time |
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Term
| What is the preferred uterine incision? |
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Definition
Low transverse unless it’s a very large fetus
Do skin and uterine incisions always match? No, for example: woman may have a vertical skin incision and low transverse uterine incision, particularly if she’s obese |
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Term
| What are the advantages to low transverse incisions? |
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Definition
| ) unlikely to rupture during subsequent births, 2) Makes VBAC possible, 3) Less blood loss, 4) Easier to repair, 5) less adhesion formation |
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Term
| What are the disadvantages of a low transverse incision? |
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Definition
| 1) Limited ability to extend laterally to enlarge the incision |
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Term
| What are the advantages of a low vertical incision? |
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Definition
| 1) Can be extended upward to make a larger incision is needed |
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Term
| What are the disadvantages of a low vertical incision? |
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Definition
| 1) Slightly more likely to rupture w/subsequent births, 2) A tear may extend the incision downward into the cervix |
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Term
| What are the advantages to the classic incision? |
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Definition
| ) May be only choice when: 1) placenta previa is implanted on lower anterior wall of uterus, 2) presence of adhesions from prior surgery, and 3) transverse lie if a large fetus with the shoulder impacted in the mom’s pelvis |
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Term
| What are the disadvantages to the classic incision? |
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Definition
| 1) Most likely of uterine incisions to rupture w/ subsequent births, 2) Eliminates VBAC as an option |
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Term
| What is done preoperatively to a c-section? |
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Definition
| bicitra for gastric acid, continued fetal monitoring, indwelling Foley catheter to drainage bag visible to the anesthesia person, grounding pad for electrocautery, shave and skin prep. Watch the partner for adverse reactions. History of previous “C” sections noted and incision types verified. |
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Term
| What are the indications of a c-section? |
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Definition
| dystocia, Cephalopelvic disproportion, hypertension, diabetes, heart disease, active genital herpes, previous uterine surgical procedures, persistent nonreassuring fetal heart tones, malpresentations, and hemorrhagic conditions. |
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Term
| What is done postoperatively for a c-section? |
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Definition
| Monitor mother for complications. Risk of hemorrhage from anesthesia. Assess vital signs q. 15 min. Arrange adequate staffing to manage the infant. Teach care of the incision. |
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Term
| What is the pre-op care for a c-section? |
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Definition
Assess
Time of last oral intake and what was eaten
Allergies
Meds taken & last dose
Informed consent for surgery, anesthesia, blood transfusion
Obtain ordered lab work
Pre-op teaching (what to expect, who will be present, etc)
Start IV and administer fluid bolus in prep for epidural
Monitor FHR
Do abdominal shave
Administer pre-op meds: Bicitra or Pepsid
Decrease stomach acid!
Insert Foley (may insert in OR after epidural is in place)
Make sure Foley drainage bag is visible during surgery…want to be able to assess that urine is clear
Assist to OR table & wedge to left side
Apply grounding pad to thigh
Do sterile prep of abdomen
Call nursery as per protocol |
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Term
| What is the post op care for a c-section? |
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Definition
Pulse ox, O2 administration, cardiac monitor
Assess for return of sensation & movement
Assess LOC if general anesthesia
q15 minute assessments x 1 hour, then q 30 min. for 2nd hour, then hourly:
VS, O2 sat
ECG pattern
Uterine fundus for firmness, height, & deviation
Lochia: color, quantity
Patency of catheter & output
Abdominal dressing for drainage
I&O
Assess fundus and vaginal lochia
Assess pain level and administer analgesia as ordered
Change position hourly
Instruct on deep breathing and coughing |
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Term
| What are the signs of hemorrhage? |
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Definition
First sign of hemorrhage…vaginal lochia!
Massage uterus if boggy or soft
Decreased urine output: an early sign of hypovolemia which occurs well before the fall in BP |
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Term
22 year old is in early labor at 37 weeks of gestation with her first baby. She was scheduled for a cesarean birth for a breech presentation the following week but her labor began early. The baby remains breech, so surgery will be done as early as possible. The woman is anxious and has many questions about what will happen to her and her baby. Her mother and husband are with her.
What is the priority nursing diagnosis for this patient? |
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Definition
| Anxiety related to unfamiliarity with the setting and procedures for cesarean birth. |
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Term
| What are goals for 22 y.o |
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Definition
State she feels less apprehensive
Verbalizes understanding of preoperative and postoperative care
Demonstrates postoperative technique for coughing and deep breathing |
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Term
She will have epidural anesthesia for her birth. Her vital signs are T-99 F, P-90 bpm, R-22 breaths/min, B/P-122/70 mmHg. The fetal heart rate is 130-140 bpm and accelerates with fetal movement. She walks to the operating room and epidural anesthesia is begun.
What is the priority nursing diagnosis? |
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Definition
| Risk for Injury related to altered sensation from epidural anesthesia and the use of electrical equipment during surgery. |
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Term
She will have epidural anesthesia for her birth. Her vital signs are T-99 F, P-90 bpm, R-22 breaths/min, B/P-122/70 mmHg. The fetal heart rate is 130-140 bpm and accelerates with fetal movement. She walks to the operating room and epidural anesthesia is begun.
Goals? |
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Definition
| She will not have injury such as pressure areas, muscle strains, and electrical injury during the perioperative period. |
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Term
She will have epidural anesthesia for her birth. Her vital signs are T-99 F, P-90 bpm, R-22 breaths/min, B/P-122/70 mmHg. The fetal heart rate is 130-140 bpm and accelerates with fetal movement. She walks to the operating room and epidural anesthesia is begun.
Appropriate nursing care? |
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Definition
Pad bony prominences
Wedge under hip
Transfer with help, brakes on, care with foley and IV
After anesthesia, position legs and safety strap
Apply grounding pad if electrocautery is used. |
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Term
A physician performs an amniotomy on a laboring woman whose cervix is dilated to 5 cm. The amniotic fluid is pale yellow, moderate in amount, and has a strong odor. The fetal heart rate is 164 beats per minute (bpm). Maternal vital signs are T-99.7, P-92, R-22, and B/P 160/80 mmHg. Contractions are moderate to firm in intensity and occur every 3-4 minutes with a duration of 50-60 sec. and complete uterine relaxation occurs.
Which of these observations should the nurse regard as normal? Which observations are abnormal? |
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Definition
| The amount of amniotic fluid is normal, but the pale yellow color and strong odor suggest chorioamnionitis, or infection of the amniotic sac. The risk for chorioamnionitis increases as the duration of ruptured membranes increases, but it can be apparent at any time, including at initial rupture. The baseline fetal heart rate is slightly elevated from the normal maximum rate at term of 160 bpm. Accelerations with fetal movement are a reassuring sign. The maternal temperature, pulse, and respirations are slightly elevated. It is difficult to interpret these values accurately, because the baseline values are not stated. These contractions are typical for a woman entering the active phase of first-stage labor. |
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Term
A physician performs an amniotomy on a laboring woman whose cervix is dilated to 5 cm. The amniotic fluid is pale yellow, moderate in amount, and has a strong odor. The fetal heart rate is 164 beats per minute (bpm). Maternal vital signs are T-99.7, P-92, R-22, and B/P 160/80 mmHg. Contractions are moderate to firm in intensity and occur every 3-4 minutes with a duration of 50-60 sec. and complete uterine relaxation occurs.
Should the nurse modify routine labor care based on the postamniotomy assessments? |
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Definition
| The nurse should continue to assess the fetus for tachycardia, which often precedes maternal fever. Assess the woman’s temperature at least every 2 hours for a temperature of 38° C (100.4° F) or higher. Report abnormalities to the physician. Observe also for fetal tachycardia and signs of fetal compromise that may occur with maternal infection. |
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Term
A woman is having labor induced with oxytocin following earlier cervical ripening with prostaglandin. Her cervix is 4cm dilated and fully effaced, head is a zero station. The nurse notes that the fetal heart rate (internal monitor) is near its baseline of 120-130 bpm with variability of 10 bpm. Contractions are firm (100mmHg with a intrauterine pressure catheter) occur every 1 ½ to 2 min. with a duration of 95-100 sec. The baseline intrauterine pressure is 25-30 mmHg.
What is the correct interpretation of these assessments? |
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Definition
| The woman is having hypertonic uterine activity, because the rest interval is often under 30 seconds. Also, her peak intrauterine pressure during contractions is 10 mm Hg higher than expected for first-stage labor, and the baseline intrauterine pressure is high. Oxytocin stimulation is the probable cause of the excessive contractions. The reassuring fetal heart rate suggests that the fetus is now tolerating the excessive contractions. |
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Term
A woman is having labor induced with oxytocin following earlier cervical ripening with prostaglandin. Her cervix is 4cm dilated and fully effaced, head is a zero station. The nurse notes that the fetal heart rate (internal monitor) is near its baseline of 120-130 bpm with variability of 10 bpm. Contractions are firm (100mmHg with a intrauterine pressure catheter) occur every 1 ½ to 2 min. with a duration of 95-100 sec. The baseline intrauterine pressure is 25-30 mmHg.
What are appropriate nursing actions in this situation and why are they done? |
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Definition
| Fetal oxygenation may be compromised if the excessive contractions continue. Reduce or stop the oxytocin infusion to decrease uterine stimulation. Increase the primary (nonadditive) intravenous infusion as needed to maintain adequate circulating volume and ensure maximum uterine blood flow. Keep the woman in a lateral position to reduce aortocaval compression and increase placental blood flow. Oxygen given at 10 L/min with a snug facemask will increase her blood oxygen saturation, making more available to the fetus. (See Chapter 18 for further information about fetal responses to reduced placental perfusion.) |
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