MATERNITY: QUIZ #5
 Prolapsed Umbilical Cord: Protrusion of umbilical cord alongside/ahead of the fetal presenting part
 Nursing Interventions
o Place in knee-chest/modified sims/trendelenburg to relieve pressure on cord
 Prolapsed Cord “Rule-Out"
o Assess FHS immediately after membrane rupture because the FHR will be unusually slow or
variable decelerations are more apparent when prolapsed umbilical cord has occurred
 Fetopelvic Disproportion: Due to fetus being too large to physically pass through maternal pelvis
 Signs &Symptoms
o Abrupt decrease in the frequency & in intensity of contractions
 Placental Abruption R/F
 Preeclampsia, Gestational HTN, Seizure activity, Uterine rupture, Trauma/Violence,
Smoking/Cocaine use, Coagulopathies, Previous hx of abruption, Placental pathology
 HYPER-tonic Uterus: Dystocia
 Contractions are erratic & poorly coordinated due to the uterus never fully relaxing in between the
contractions
 Uterus dysfunction occurs during latent phase of 1st trimester; Stays at 2-3cm/ No progress with
contractions causing mother to become discouraged & fatigued
 Places fetus at risk for abruption + precipitous delivery
 Nursing Interventions
o Provide rest;
o Assist with procedures to “rule out” disproportion & malpresentation/Assist with amniotomy
(augmentation)
o Monitor FHR for S/S of fetal distress (decreased placental perfusion ->compromises fetus);
o Monitor for S/S of infection
o Promote hydration with IV fluids
o Administer pain relief measurements as ordered such as epidurals & analgesia
o Explain/inform patient about procedures, dysfunctional labor pattern & expectations
o Plan for a possible operative birth
 HYPO-tonic Uterus: Dystocia
 Labor BEGINS normally & then decreases; Occurs during the active phase of labor (≥4cm)
 Uterus relaxes too much causing contractions to be weak, milder, infrequent, shorter, poor in quality
& lacks the sufficient intensity to dilate/efface cervix /Ineffective contraction
 MAJOR RISK: POSTPARTUM HEMORRHAGE
 Nursing Interventions
o Administer uterine stimulants such as oxytocin as ordered & only when fetopelvic
disproportion has been ruled out
o Assist with amniotomy
o Continuous fetal monitoring
o Monitor vital signs, contractions & cervix
o Assess S/S of maternal & fetal infection
o Explain/inform patient & family about dysfunctional labor patterns, procedures &
expectations
o Prepare for cesarean if attempts are unsuccessful
 Cervical Insufficiency
 Typically occurs in the 2nd trimester due to heavy gravid uterus putting pressure on weakened cervix
 May lead to abortion
 Preterm Labor: Regular/persistent uterine contractions with cervical effacement/dilate before completion
of 37 weeks; Leading cause of death in the 1st month of life; 2nd leading cause of all infant
deaths
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Risk Factors
o African American (doubled risk)
MATERNITY: QUIZ #5
o Hx of preterm birth (Tripled risk)
o Cervical insufficiency
o Maternal Age < 16 or > 40
o Late or no prenatal care
o Infection (UTIs/BV/STI/Chorioamnitis)
 Diagnostic Testing
o CBC/UA/C&S (detect infection)
o Amniocentesis to determine fetal lung maturity & chorioamnitis
o Ultrasound (cervical length)
o Fetal Fibrinogen (FFN)
 Signs & Symptoms: May be subtle & overlooked
o Dysuria (difficulty voiding); Pelvic pressure; Low-dull backache; Change/Increase in
discharge (water/blood/mucous)
o >6cm dilation/hour & Intestinal cramping with or without pain
o Nausea/Vomiting
 Nursing Interventions
o Administer tocolytics as ordered
o Provide education/psychological support during preterm labor process
 Medications
o Tocolytics; Corticosteroids & Antibiotics (GBS prophylaxis/other suspected infections)
 Patient Teaching
o When experiencing ANY signs of preterm labor, stop what you’re doing & rest for 1 hour,
o Drink several glasses of water; Empty bladder
o Lie down on her side, Feel abdomen & note hardiness of contractions
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Notify OB immediately
o ACTIVITY RESTRICTIONS
 Shoulder Dystocia (MEDICAL EMERGENCY/UNEXPECTED)
o Most common cause is due to an increased birth weight/macrosomia & is the
obstruction of fetal shoulders after head is delivered
o Risk for injury (nerve damage with palsy/clavicle &humeral fracture/neonatal ashyxia)
o Risk for postpartum hemorrhage secondary to uterine atony/vaginal lacerations
 Nursing Intervnetions
o Perform McRoberts’s Maneuver; Apply suprapubic pressure; Place into
squatting/hand-knee/lateral recumbent
o Alert pediatrician/anesthesia/staff
o Inform patient/family about steps being taken next
o EMPTY BLADDER
o Anticipate cesarean if not successful
 PROMPT RECOGNITION/APPROPIATE MANAGEMENT WLL DECREASE SEVERITY OF
INJURY
 Hematoma: Expected Signs & Symptoms
 Bright-red vaginal bleeding
 Localized Bluish bulging area in perineal
 Severe perineal/pelvic pain
 Difficulty voiding/Impaired urinary elimination
 Forceps/Vacuum Extraction
 Forceps Extraction Indications
o Failure of full rotation of fetal presenting part/Descended into pelvis
o Prolonged 2nd stage of labor
o Abnormal FHR patterns
o Acute Pulmonary Edema
MATERNITY: QUIZ #5
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o Compromised pushing sensation due to anesthesia
 Increases the Risk of Developing: Caput Succedaneum, Cephalhematoma, Ecchymosis,
Face/scalp lacerations & Facial nerve injury
Uterine Rupture: First & most reliable sign of sudden fetal distress
 Signs & Symptoms
o Acute abdominal pain
o Vaginal bleeding
o Hematuria
o Irregular wall contour
o Loss of station in fetal presenting part
 Risk Factors
o Crack cocaine use
Indications for Labor Induction
 Chorioamnionitis
 Ripened Cervix
Amniotic Fluid Embolism
 Signs & Symptoms
o Sudden onset of respiratory distress; ARDS
o Hypotension/Tachycardia/Cyanosis
o Pulmonary edema
o Uterine atony with subsequent hemorrhage
o Cardiac arrest; Seizures
 Nursing Interventions
o Administer O2 via nonrebreather facemask to compensate for blockage of blood flow through
lungs
Amnioinfusion
 Instillation of a warm, sterile volume of lactated ringers or normal saline into the uterus via
intrauterine pressure catheter.
 Indications
o Severe variable decelerations due to cord compression
o Oligohydramnios (decreased amniotic fluid)
o Maternal age >35
o Preterm labor with membrane rupture
o Thich meconium fluid
Ripe Cervix
 Cervix is shortened, centered (anterior), softened & partially dilated
Unripe Cervix: Cervix is long, closed, posterior & firm
 Mechanical Ripening Method
o Laminaria
 Nonpharmalogical Ripening Method
o Herbal agents
 Surgical Ripening Methods
o Membrane stripping & Amniotomy
Bishop Score >8
 Indication for successful vaginal delivery
Bishop Score <6
 Indication that cervical ripening methods should be performed prior to induction
Dystocia: Failure of labor progression/Abnormal labor
 Precipitate Labor
o 3 hours from 1st contraction to delivery
o Maternal complications are rare with adequate pelvis/soft tissue
MATERNITY: QUIZ #5
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Possible Complication of Precipitate Labor
o Cervical lacerations; Uterine rupture
o Fetal head trauma (intracranial hemorrhage/nerve damage)
 Anxiety Producing Labor
o Very little time for rest between contractions
o Contractions are intense
 Protracted Disorders (Powers)
o Slower than normal dilation/descent
o Labor lasting >18-24 hours
o Primip Dilation of 1.2cm/hour & Decent of <1cm/hour
o Multip Dilation of 1.5cm/hour & Descent of <2cm/hour
 Arrest Disorders (Powers)
o Secondary Arrest of Dilation/No dilation in >2hours
o Arrest of Descent/No descent of fetal head in 1hour for Primip & 0.5hours for Multip
o Failure of descent (No decent at all)
 Nursing Interventions
o Closely monitor women with history
 Risk Factors
o Epidural analgesia/Excessive analgesia
o Multiple gestations/Nulliparity
o Short maternal stature/Maternal Age >35/Maternal exhaustion/ Gestational age >41 weeks
o Hydramnios/Chorioamnionitis/Overweight/ Ineffective pushing technique
o Prolonged 1st stage of labor/Ineffective uterine contractions
o Occiput posterior positioning; Macrosomia/Breech presentation/Shoulder dystocia
o Fetal anomalies (hydrocephalus)
o Excessive caffeine intake
o Complete dilation/High station at complete dilation
 Common Passenger Problems of Dystocia
 Occiput posterior positioning
o Occurs in 15% of woman; Labor is longer & more uncomfortable (back pain)
o Comfort measures (massage/pressure/ice/reposition)
o Anticipate use of forceps to rotate head
 Signs & Symptoms
o Severe lower back pain
 Nursing Interventions
o Provide adequate pain relief measures is priority
o Massaging the patients lower back may also provide pain relief
o After providing pain relief measures, place patient in the hand-knee position to promote fetal
head rotation
 Occiput Anterior Positioning
o Most favorable; Any variation/or different presentation increases risk for dystocia
o Affects contractions/fetal descent
 Breech presentation
 Macrosomia
 Multifetal pregnancy
 Structural anomalies
 Cephalopelvic Disproportion (CPD)
 Fetal Risks due to Prolonged Pregnancy
 Increased amniotic fluid volume
 Macrosomia
 Shoulder dystocia
MATERNITY: QUIZ #5
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 Low APGAR score
 Brachial plexus injuries
 Postmautrity Syndrome
 Cephalopelvic Disproportion
Postmautrity Syndrome
 Fetal weight gain in the uterus after the due date & is usually due to a problem with delivery of blood
to the fetus through the placenta, leading to malnourishment
Cesarean Delivery Indications
 Previous cesarean/Classic uterine incision
 Breech presentation/Malpresentation/ Dystocia/Macrosomia/Fetal Distress
 Placenta Previa/Abruptio Placentae/ Fetopelvic Disproportion/Umbilical cord prolapse
 Congenital Anomalies including: Neural tube/Abdominal wall defects & Hydrocephalus
 Gestational HTN/Diabetes/Active Genital Herpes/HIV+
Cytotec Adverse Effects
 Hyperstimulation of uterus that may progress to uterine tetany with marked impairment of
uteroplacental blood flow
 Uterine Rupture
 Amniotic Fluid Embolism
Mastitis: Commonly caused due to Staphylococcus Aureus Infection
 Signs & Symptoms
o Red, hard/distended, tender/painful, red/hot area on affected breast
 Risk Factors
o Nipple Piercings
 Nursing Interventions
o Application of warm or cold compresses help to provide comfort
o Breastfeeding should be continued/Perform hand hygiene prior to breastfeeding to prevent
mastitis; If unable to breastfeed, manually expel breast milk every 1-2 hours
Postpartum Hemorrhage
 Uterine Atony is the #1 cause of postpartum hemorrhage
 Mild S/S of Shock
o Diaphoresis, Increased capillary refill, Cool extremities & Maternal anxiety
 Moderate S/S of Shock
o Tachycardia & Oliguria
 Severe S/S of Shock
o Confusion
 Prevention of postpartum Hemorrhage
o Perform a thorough inspection of placenta to confirm intactness following delivery
o Fragments/Tears left inside may indicate accessory lobe or placenta accreta which lead to
profuse postpartum hemorrhaging because the uterus is unable to fully contract
 Oxytocin/Methylergonovine/Carboprost are administered to manage postpartum
hemorrhaging
Prolonged Labor with Premature Membrane Rupture
 Priority Nursing Interventions
o Monitor mother & newborn for signs of an infection
o Inform patient to take antibiotic as prescribed until finished;
o Wash hands before & after perineal care; Handle perineal pads by the edges & Direct
peribottle so flow is front-back
o Assess temperature daily + Notify OB of temp >100.4
Hematoma
 Expected Signs & Symptoms
MATERNITY: QUIZ #5
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o Bright-red vaginal bleeding
o Localized Bluish bulging area in perineal
o Severe perineal/pelvic pain
o Difficulty voiding/Impaired urinary elimination
Uterine Laceration Expected S/S
 Firm uterus with a steady stream/trickle of unclotted bright-red blood in perineum
Risk Factors Associated with Uterine Tone
 Hydramnios
 Rapid/Prolonged Labor
 Oxytocin use
 Maternal Fever
 Prolonged Rupture of Membranes
Risk Factors Associated with Retained Uterine Tissue
 Retained Blood Clots
Risk Factors Associated with Genital Tract Trauma
 Fetal Malposition
 Operative Birth
Pulmonary Embolism due to Thromboembolism
 Priority Signs & Symptoms
o Dyspnea
o Diaphoresis
o Hypotension/Tachycardia
o Sharp, Stabbing Chest Pain
o Apprehension
o Hemoptysis
o Syncope
o Sudden Change in Mental Status due to Hypoxia
 Nursing Assessment Priority
o Assess for pedal edema
 Prevention
o Avoid prolonged periods of sitting
VBAC (Vaginal birth following at least 1 cesarean )
 Offered to women with low-transverse uterine incisions
 HIGH RISK FOR UTERINE RUPTURE & HEMORRHAGE/RISK LOW BUT HIGH FETAL
MORTALITY
 Contridictions
o Classical cesearean; Any uterine scars
 Nursing Considersations (IMPORTANT)
o Obtain consent; Documentation; Surveillance; Readiness for emergency
Calf Pain on Dorsiflexion of the Foot Indicates
o DVT
o Strained Muscle Contusion
Perineal Pain with Swelling along Episiotomy
o May be normal or may indicate infection
Leg Pain on Ambulation with Mild Edema Indicates
o Superficial Venous Thrombosis
Postpartum Depression Indications
 Restlessness; Worthlessness; Guilt; Hopelessness; Sadness; Loss of enjoyment; Low energy; Loss of
libido; Insomnia; Anxiety; Loss of confidence; Inability to concentrate
Postpartum Blues Indications
 Feeling overwhelmed; Fatigued & Changing of moods
MATERNITY: QUIZ #5
 Postpartum Psychosis
 Depression escalates into Delirium; Hallucinations; Anger toward self & infant; Bizarre behavior;
Mania; Suicidal thoughts towards self & infant; Incoherently speaking; Disoriented thought process
& Frequent obsessive concerns; Difficulty relaxing
 Abruptio Placentae: Complication of DIC
 Signs & Symptoms
o Petechiae
o Ecchymosis/Signs of impaired clotting
 Subinvolution: Usually identified at 4-6 weeks gestation
 Signs & Symptoms
o Postpartum fundal height greater than expected
o Boggy Uterus
o Lochia Color Change Fails
 Fundal Massage
 Uterus must be firm prior to attempting to express clots because firm pressure on uncontracted
uterus may lead to uterine inversion
 One hand is placed on the fundus, while other hand is placed above symphysis pubis
 Massage in circular motions
 Be aware of not over-massaging because uterine tissue responds quickly to uterine touch
 Oxytocin Therapy
 Action
o Uterine stimulation
o Administered for uterine atony/bleeding leading to postpartum hemorrhage & hypotonic
uterine dysfunction
o Induction of labor
 Nursing Administration Considerations
o Oxytocin should be diluted into 1L IV Solution as an IV piggy-back into primary line
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Nursing D/C Considerations
o Discontinue for prolonged contractions & an abrupt onset of headache, dizziness,
nausea/vomiting; Notify OB immediately
o Oxytocin therapy may cause water intoxication causing urine output <30mL/hour +
uterine resting tone >20mmHg and requires immediate intervention
 Tocolytic Therapy
 Purpose
o Helps to control preterm labor/promote uterine relaxation
 Medications (Off-Label)
o Magnesium Sulfate: Reduces muscles ability to contract)
o Terbutaline (Brethine/Beta-Adrenergic): Relaxes smooth muscle
o Indomethacin (Indocin/Prostaglandin)
o Nifedipine (Procardia/Calcium Channel Blocker)
 Contradictions
o Abruption; Acute Fetal Distress; Fetal Death; Eclampsia; Severe preeclampsia; Active
Vaginal Bleeding; Dilation >6cm; Chorioamnitis; Maternal Hemodynamic Instability
 Magnesium Sulfate
o Expected S/S: Headache, Blurred vision & Hypotension
 Magnesium Toxicity S/S: Diminished deep tendon reflexes; Respiratory Rate <12
breaths/minute; Urine output <30 mL/hour; Decreased level of consciousness
 Corticosteroids Purpose
MATERNITY: QUIZ #5
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Administered for preterm labor (PTL); Helps prevent/reduce severity of respiratory distress
syndrome in preterm infants born at 24-24 weeks
 Nursing Interventions
o Monitor for maternal infection & pulmonary edema
o Assess maternal L/S ratio
o Provide education regarding potential benefits
o Administration of 2 doses IM 24hours apart
o Benefits are seen in 24-48hours;
o May repeat dosing in 7 days or more from initial dose;
 Medications for Cervix Ripening
 Dinoprostone (rectal/vaginal)
 Misoprostol
 Methylergonovine
 NEVER ADMINSITER IF PATIENT IS HYPERTENSIVE