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M6 13-005

Exam 9: Special Situations in L&D

Amniotomy rupture of the membranes (amniotic sac) by using a disposable plastic hook (Amnihook).
Amniotomy: Indications : usually performed in conjunction with induction and augmentation of labor and to allow internal electronic fetal monitoring.
Amniotomy: Risks Prolapse of umbilical Cord Infection Abrupto Placentae
Amniotomy: Nursing Considerations MONITOR FHR for 1 MIN!!! Record fluid Take Mom's Temp Peri-Care
Induction of Labor Artificial initiation of labor
Augmentation of Labor artificial stimulation of contractions that have begun spontaneously but progress has slowed or stopped, even if contractions seem to be adequate.
Reasons to Induce Labor Intrauterine hostile environment. Hypertension. PROM Post-term Pregnancy Chorioamnionitis Abrupto Placenta Maternal Medical Conditions Fetal Death
Cervical ripening procedures to ripen (soften) the cervix and make it more likely to dilate with the forces of labor; usually done the day before the scheduled induction
Cervical ripening: Medical Methods -prostaglandin E2: may be given as an intravaginal gel, an intracervical gel or a timed released vaginal insert. I-V oxytocin (Pitocin)
Mechanical methods laminaria tents foley bulb
most common drug given for induction and augmentation of labor. Pitocin (oxytocin)
Pitocin (oxytocin): Risks Hypertonic uterine activity. Uterine Rupture Maternal Water Intoxication
Pitocin (oxytocin): Nursing Interventions Steps to reduce uterine activity. Reduce or stop infusion. Keep woman off her back.
Pitocin (oxytocin): Nursing Considerations Hypertonic Reactions can reduce placental bloodflow. Baseline VS. Monitor FHR q 15mins during 1st stage, q5 mins during 2nd stage.
External cephalic version (ECV) changes fetal position from a breech, shoulder (transverse lie), or oblique presentation; successful ECV may avoid need for a C section
Internal Version malpresentation in twin gestations is usually managed by C section, but internal version is sometimes used for vaginal birth of second twin. A fetal part (usually a leg or foot) is grasped through the cervix and used to turn and deliver the infant.
Version: Contraindications Uterine Malformations. Previous C section. Fetal size ≥ 4000g Disproportion between fetus and pelvis. Placenta Previa. Multifetal gestation. Ruptured membranes or cord around body or neck. Uteroplacental insufficiency. Fetus head into pelvis.
Version: Risks Fetus entangled in umbilical cord. Abrupto Placentae. Fetal and maternal blood mix. C-section for fetal compromise.
Operative vaginal births (forceps or vacuum extractor) may be used by physician to apply traction to the head during birth, to aid expulsive efforts.
Forceps curved, metal instruments with two curved blades that can be locked in the center.
Piper forceps special type used to deliver the fetal head during a breech delivery.
Vacuum extractor suction to grasp the fetal head while traction is applied
Episiotomy the surgical enlargement of the vagina during birth
Lacerations a tear in the perineum, vagina or cervix
Classifications: 1st and 2nd degree laceration usually uncomplicated and heal quickly because they don’t affect the rectal sphincter.
Classifications: 3rd degree laceration extend to the rectal sphincter
Classifications: 4th degree laceration extend completely through the rectal sphincter
Operative cesarean birth: Indications Dystocia Cephalopelvic disproportion Hypertension Maternal disease, if labor unadvisable Active genital herpes Prior cesarean or prior ABD Sx Persistent non reassuring fetal heart rate patterns Prolapsed umbilical cord Fetal malpresentation
Problems with Powers of Labor may not be adequate to expel the fetus because of ineffective contractions or ineffective maternal pushing efforts.
HYPOtonic Labor Dysfunction contractions are coordinated but too weak to be effective. The women start off with normal labor then the contractions diminish in the active phase. (During active phase of labor 4cm)
HYPERtonic Labor Dysfunction contractions are uncoordinated and erratic in their frequency, duration, and intensity. They are painful but ineffective. Usually occurs during the latent phase of labor.
Problems with the Passenger Fetal Size. Abnormal Fetal Presentation or Position. Multi-fetal Pregnancy
Macrosomia a large fetus, generally weighing over 4000 gm (8 lb 13 oz) or more at Birth; head may be so large it can’t mold to the pelvis.
Shoulder dystocia Delayed or difficult birth of the shoulders may occur as they become impacted above the symphysis pubis. As the head emerges it retracts (“turtle sign”).
Abnormal Fetal Presentation or Position an unfavorable fetal presentation or position may interfere with cervical dilation or fetal descent.
Rotation abnormalities persistence of the fetus in the occiput posterior or occiput transverse position can contribute to dysfunctional labor.
Deflexion abnormalities poorly flexed fetal head presents a larger diameter to the pelvis than if flexed with chin on chest
Breech presentation Cervical dilation and effacement slower because the buttocks or feet do not form a smooth, round dilating wedge like the head
Trial of labor if... a. Maternal pelvis is normal size and shape b. Estimated fetal weight is 2000 to 3800 g (4.4 to 8.4 lb) c. The fetal head is well flexed
Problems associated with a breech birth a. Fetal injury b. Prolapsed umbilical cord c. Low birth weight due to preterm gestation, multifetal pregnancy, or intrauterine growth restriction d. Fetal anomalies e. Complications secondary to placenta previa or cesarean birth
Problems with the Passage: Pelvis (Small) A small or abnormally shaped pelvis may retard labor and obstruct fetal passage
Gynecoid most common (50%) and most favorable for vaginal birth, pubic arch is wide.
Anthropoid anteroposterior diameter is longer than the transverse diameter. Narrow pubic arch
Android heart or triangular-shaped inlet. Narrow pubic arch. Poor prognosis for vaginal delivery (incidence 30%).
Platypelloid flattened: wide, short, and oval. Transverse diameter wide but anteroposterior diameter short. Poor prognosis for vaginal delivery (incidence 3%).
Problems of the Psyche: excessive or prolonged stress interferes ↑ glucose consumption, ↓ energy supply to contracting uterus.
Prolonged Labor results from problems with any of the factors in the birth process
Average rate of cervical dilation in the active labor phase is: 1.2 cm/hr in the nullipara, and 1.5 cm/hr in the parous woman.
Precipitate Labor a labor that is completed in less than 3 hours
PROM (premature rupture of membranes) rupture of the amniotic sac before onset of true labor.
PPROM (preterm, premature rupture of the membranes) rupture of membranes earlier than the end of the 37th week of gestation, with or without contractions. Associated with preterm labor and birth.
Chorioamnionitis Inflammation of the amniotic membranes caused by infection.
Complications with PROM Chorioamnionitis Oligohydramnios Umbilical cord compression Reduced lung volume and deformities
Oligohydramnios deficiency in the amount of amniotic fluid.
Preterm Labor (PTL) after 20 and before the end of the 37th week (38 weeks) gestation
Signs and symptoms of PTL (a)Contractions that may or may not be painful. (b)baby is “balling up” frequently. (c)Menstrual-like cramps. (d)Constant low backache. (e)Pelvic pressure. (f)change in vaginal discharge. (g)ABD cramps. (h)Pain, discomfort, or pressure.
Predicting Preterm Birth Short cervical length. Previous preterm birth. Positive fetal fibronectin (fFN) screening result after 22 weeks. Infection.
Accelerating fetal lung maturity: Meds Corticosteroids (if before 34 weeks inevitable). Dexamethasone and betamethasone (24 to 34 weeks of gestation)
Prolonged pregnancy longer than 42 weeks
Prolonged pregnancy: Fetal placenta ages it delivers oxygen and nutrients to the fetus less efficiently. Growth Retardation. Meconium. Oligohydramnios. If placenta is not functioning efficiently the fetus will not tolerate labor.
Prolonged pregnancy: Maternal added fatigue diminishes resources for tolerating more stress and anxiety about labor and birth as she feels as though the pregnancy will never end.
Prolapsed umbilical cord the cord slips downward after the membranes rupture, subjecting it to compression between the fetus and pelvis.
Prolapsed umbilical cord: Complete the cord can be seen protruding from the vagina.
Prolapsed umbilical cord: In front of head cord cannot be seen but it can be felt as a pulsating mass during vaginal exam.
Prolapsed umbilical cord: occult (Hidden) the cord is compressed between the fetal presenting part and pelvis but cannot be seen or felt during vaginal exam.
Prolapsed umbilical cord: Management Position: Knee-chest. Trendelenburg. Hips elevate with pillows, with side-lying maintained.
Uterine rupture: a tear in the uterine wall that occurs if the uterine muscle cannot withstand the pressure against it. May precede labor’s onset.
Uterine rupture: Complete a direct communication between the uterine and peritoneal cavities.
Uterine rupture: Incomplete a rupture into the peritoneum covering the uterus or into the broad ligament but not the peritoneal cavity.
Uterine rupture: Dehiscence a partial separation of an old uterine scar. Little or no bleeding may occur. No signs or symptoms may exist and the rupture may be found incidentally during a subsequent C section or other abdominal surgery.
Uterine rupture: Causes Previous uterine Sx. high parity w/ a thin uterine wall. Intense contractions may exceed uterine wall strength. Blunt ABD trauma.
Uterine rupture: S/S Asymptomatic Hypovolemic shock ABD pain and tenderness. Chest pain (d/t blood below diaphragm). Cessation of contractions. Abnormal FHR. Palpation of fetus outside of uterus.
uterine Inversion Occurs when the uterus completely or partly turns inside out, usually during 3rd stage of labor.
Uterine Inversion: Causes Fundal pressure during birth. Pulling on the umbilical cord before the placenta detaches from the uterine wall. Fundal pressure on an incompletely contracted uterus after birth. Abnormally adherent placenta Uterine weakness Fundal placenta implantati
Uterine Inversion: S/S Absent uterus from the abdomen or a depression in the fundal area Protrusion of the interior of the uterus into the vagina or through cervix
Amniotic fluid embolism occurs when amniotic fluid, with its particles such as vernix, fetal hair, and sometimes meconium, is drawn into the maternal circulation and obstructs pulmonary vessels.
Trauma due to accidents, assault, or suicide. Battering is a significant cause of trauma during pregnancy.
Created by: jtzuetrong