Marian University NSG 307

NSG 307 Final Exam Study Guide 

NSG 307 Care of the Childbearing Client – Final Study Guide
Ch 17
 Assessment and care of preterm labor (PTL)
o preterm birth - between 20 weeks and 0 days and 36 weeks and 6 days
 12% of babies in the United States are born prematurely
 refers strictly to the gestational age of the baby
 very preterm (20 weeks to 32 weeks)
 moderately preterm
 late preterm (34 weeks 0/7 days to 36 weeks 6/7 days) (most common – 75%)
 COMPLICATIONS: death, mental and physical disability (Cerebral Palsy, visual problems,
feeding problems, hearing loss, and developmental delay)
 all possible measures are taken to decrease elective births before 39 weeks
 Preterm birth whereas low birth weight
 Spontaneous – absence of maternal and/or fetal illness (75% of preterm births)
 Indicated – due to maternal or fetal risk to continuing pregnancy – iatrogenic
 fetal fibronectin test – negative = preterm birth NOT likely
 Cervical length is a predictor of the possibility of preterm birth
 > 30 mm in 2nd/3rd trimester = unlikely to have preterm birth
o low birth weight (< 5.5 lbs/2500 grams at birth) = most important predictor of infant health
 8% of babies are born at low birth weight
 can happen at any gestational age
 may have mature organs, however has been subjected to chronic uteroplacental circulation
issues or poor maternal nutrition (IUGR)
 TOCOLYTIC THERAPY: to suppress uterine activity and stop to progress of PTL:
o currently no FDA approved medications for PTL
o Magnesium Sulfate – CNS depressant; relaxes smooth muscles
o Terbutaline (β-agonist) – fast acting; relaxes uterine smooth muscle & causes bronchodilation
 concerning side effects (rapid HR, risk for pulm edema) – not used long-term
o nifedipine (Procardia) – calcium channel blocker (risk – reduced BP)
 prevents calcium from entering smooth muscle cells
o indomethacin (Indocin) – used to relax smooth muscle by inhibiting prostaglandins
o All of these drugs come with potential harm to both Mother and baby, so the risks must outweigh
the benefits while these drugs are being used (mediation guide pp 426-428)
 Glucocorticoids (betamethasone, dexamethasone) promote fetal lung maturity in the event that preterm
labor is inevitable
 PROM – premature rupture of membranes – occurs before onset of labor (any gestational age)
-VSpPROM – preterm premature rupture of membranes – occurs before 37 weeks 0/7 days
o CAUSE: pathological weakening of the sac caused by inflammation (infection), Uterine contraction
Stress from increased intrauterine pressure (multiple births)—see box 17.6
o SX: sudden gush of fluid or a trickle of fluid.
o MGMT: depends on how far the pregnancy has advanced before the ROM
 If at term, more than likely labor induction will be advised bc of the risk for infection
 If 34-37 weeks gestation, conservative management considered if infection risk is low
 If before 32 weeks, woman will be hospitalized, watched for infection and FHR reassurance,
and allowed time for the fetus to continue to mature.
 Corticosteroid and antibiotics improve outcomes for both Mother and baby.
 Mag Sulfate may be admin – fetal neuroprotective qualities if birth imminent.
 Induction of Labor (IOL) = Chemical or mechanical initiation of uterine contractions before spontaneously
occurring on its own
o Bishop score – evaluates inducibility – how “ripe” and favorable a cervix is for labor and birth
 5 ways that the cervix progresses during labor and birth
 score of 0 = cervix is unfavorable for IOL
 score of 13 = cervix is very favorable.
 score totals ≥ 8 = likelihood of vaginal birth similar whether spontaneous or induced
o To prevent prematurity, ACOG recommends pregnancy be at end of week 39 before IOL

o Methods of Cervical Ripening (Labor Induction):
 Chemical agents – prostaglandins (Cytotec, Cervidil Insert, Prepidil Gel)
 possible side effects – tachysystole with nonreasurring FHR pattern
passage of meconium into the amniotic fluid
 Mechanical dilators – Balloon catheters, Hydroscopic dilators (pg 440)
 work by releasing the endogenous prostaglandins at the cervix
 Alternatives – Blue and Black cohosh, castor oil, Evening Primrose oil, acupuncture
 Amniotomy (AROM) – used to induce a favorable cervix or augment a slowing labor
o oxytocin (Pitocin) - produced synthetically; used for an IOL or for labor augmentation
 High-alert medication bc of hazards if used in error (most common is dosage error)
 titrated through a secondary PIV line
 started at a low dose and increased periodically (no sooner than every 30-40 mins) until a
good labor pattern is established (contractions every 2-3 minutes)
 GOAL: to achieve as close to a labor pattern as possible using lowest dose possible
 Continuous fetal monitoring required –
 possible side effects = tachysystole, and fetal stress
o tachysystole – 5 or more ctxns in a 10 min window, avg over 30 min
o If uterine tachysystole occurs, emergency protocol: (see p 445)
 also to help uterus to maintain a strong uterine contraction directly afer birth to treat
uterine atony and hemorrhage
 Nursing care of the patient undergoing a cesarean birth
o If the baby cannot be delivered via a vaginal birth
o forceps-assisted birth or vacuum-assisted ofen tried first if deemed safe
o C/S is the most common major surgical procedure done in the USA
 The CDC reports our C/S rate is at 32% for the year 2015 = HIGH
 WHO has asked that we lower C/S rate for safety and well-being of mothers/babies.
o Some C/S are elective, some are scheduled, and some are unplanned…
 best outcomes/most satisfying experiences are when the woman is supported and able to
help in the decision-making process to meet her psychosocial needs.
o surgical technique and types of incision must be recorded (esp. in case of future pregnancies)
 Some uterine incisions are more prone to uterine rupture (vertical)
 type of incision (transverse or vertical), will help the providers to advise her with future labor
and birth planning.
BELOW: two types of SKIN incisions 1) vertical 2) transverse/horizontal/bikini/Pfannenstiel
BELOW: types of UTERINE incisions (A = low transverse) (B and C = vertical)
*surgeon makes this decision based on the position of the placenta and baby’s position
*vertical incision - the risks of uterine rupture rises in future pregnancies
(VBAC will not be advised afer this type of incision)
*low transverse incision (A) - most common; less blood loss, TOL possible in future pregs.
o complications and risks – hemorrhage, bowel or bladder injury, amniotic fluid/air embolism
o Risks to baby as well – prematurity if the due date is incorrect, fetal asphyxia (perfusion issues from
regional anesthesia), fetal injuries, respiratory issues (more common with a C/S)
o LABS and DIAGNOSTICS – CBC, T&S, maternal assessments include a H&P, complete set of V/S,
Admission assessment, and fetal monitoring
o Informed consent must be signed including a consent for the anesthesia
o Anesthesia utilized (Spinal, epidural, general) – has its own associated risks
(Intubation, drug reactions, aspiration, BP issues with regional anesthesia, N/V)
 regional anesthetic agent usually used (either a spinal or epidural)
 IV fluids are started, and a bolus dose of IVF are placed before the regional anesthetic
 anticipate drop in BP that accompanies that type of anesthesia
 many times, a dose of antibiotic is given prophylactically
o C/S room: 3 scrubbed staff (surgeon, assistant, and surgical nurse)
 circulating nurse in the room preparing the woman for surgery, providing needed assistance
during the surgery, and birth recorder
 anesthesiologist is present – once anesthesia is placed, the risk for a drop in the Mother’s BP
is immediate
 woman is placed with a wedge under one hip to displace the uterus to the side
 may have N/V due to the rapid BP drop
 FHR is monitored closely
 foley catheter is placed
 SCDs are placed on her legs during the surgery
 Afer birth, Pitocin is added to IVF to help uterus contract and reduce bleeding
o usually only 10 min from the start of the surgery to the birth of the baby
o remainder of the surgery takes about 30-45 min
 sewing the layers back together, paying particular attention to cauterize any arterioles that
may pose a problem with postop hematoma formation.
o NICU staff (neonatologist, nurse, respiratory therapist) is usually called and are present to provide
any immediate aid to the newborn upon birth and if baby is pink, breathing well, and not needing
immediate assistance, the baby is wrapped and offered to the parents to hold and then both Mother
and baby are transferred together to the PACU.
o PACU: **nurse has 2 patients to care for**
 V/S, bleeding, pain, N/V, I & O, initiation skin-to-skin and breastfeeding
 PO clear liquids can be started
 Pain is controlled through the regional anesthetic, PCA
o Postoperative PP care – assessments for any post-surgical complications:
 Atelectasis, endometritis, UTI, abdominal wound hematoma, dehiscence, infections, DVT,
bowel dysfunction (pain from intestinal gas)
Ch 21
 Postpartum Complications – PPH, VTE, Coagulopathies, infection, mood disorders, death
 PP Hemorrhage (PPH) – causes woman to become hemodynamically symptomatic, even hypovolemic shock
 loss of ≥ 500mL blood afer vaginal birth or ≥ 100mL blood afer cesarean birth
 10% change in Hct from admission to postpartum period
 need for erythrocyte transfusion
o Diagnosis – ofen based on subjective observations; blood loss ofen underestimated as much as 50%
o Early/Acute/Primary – within 24 hours of birth
o Late/Secondary – more than 24 hours but less than 6 weeks afer birth
o Incidence – leading cause of maternal morbidity and mortality in U.S. and worldwide
o Etiology and risk factors