Chapter 23

Nursing Care of a Family Experiencing a Complication of Labor or Birth

CD PATIENT SCENARIO

CARE STUDY: A WOMAN WITH A COMPLICATION OF LABOR

Molly Deska is a 24-year-old, G3P1, 37-week pregnant woman admitted to the maternity

service in active labor.

CHIEF CONCERN:

"I'm in labor, but there's something wrong."

HISTORY OF CHIEF CONCERN:

Molly was alerted at her last prenatal visit that her fetus was in a posterior position so

labor might be long. Contractions began 8 hours ago; pattern has never become regular.

Contractions are presently 5 to 30 minutes apart; duration about 30 seconds. She is

having such back pain with contractions she asks to have something for pain relief.

FAMILY PROFILE:

Client not employed as she volunteers days at center for children who are cognitively

challenged where her older son attends preschool and volunteers as a waitress in

grandparents’ business in the evenings. Husband works as a garage mechanic. Finances

are "tight." Couple lives in a furnished apartment above a tavern that her paternal grand-

parents own. Marriage is "shaky" due to strain of finances, family disagreements, and

"getting married before we knew each other very well."

HISTORY OF PAST ILLNESSES:

Near-drowning accident in neighbor's pool at 2 years; revived by paramedics with no

apparent sequelae; tonsillectomy at 7 years. No major illnesses or hospitalizations except

for previous childbirth.

HISTORY OF FAMILY ILLNESSES:

Maternal aunt has child with Down syndrome, Molly's father died of liver failure from

alcoholism at 45. Husband's family has "many" people with peptic ulcers.

GYNECOLOGICAL HISTORY:

Menarche at 14 years; cycle duration: 28 days; length of menstrual flow: 7 days. Treated

for exposure to syphilis at 18 years. Was using vaginal foam as contraceptive before

deciding to become pregnant.

OBSTETRICAL HISTORY:

Spontaneous abortion 4 years ago. Boy, 8 pounds 4 ounces, vaginal delivery, born 3 years

ago with Down syndrome. Present pregnancy was planned and welcomed. Attended late

for prenatal care (6th month) because of finances. No amniocentesis or CVS for

chromosomal studies done because of lateness of care. No preparation-for-labor class

attended. "Not interested in being brave" given as reason.

DAY HISTORY:
Nutrition: 24-hour nutrition recall reveals diet high in carbohydrate and low in protein.

Prenatal vitamin not taken “because of finances.”

Sleep: Sleeps 6 hours at night. Bar downstairs is “too noisy” until after 3 a.m. to sleep

before that.

Recreation: Does not participate in an active exercise program. Walks “lots” every

evening that she fills in as a waitress.

PHYSICAL EXAMINATION

General Appearance: Distressed and exhausted appearing, obese, young adult pregnant

woman. Height: 5'3"; weight: 170 lbs; BP: 135/86.

HEENT: negative.

Chest: Heart rate: 76 beats per minute; physiologic splitting marked. Lungs: clear to

auscultation; respiratory rate: 20 breaths per minute.

Abdomen: Fundal height: 38 cm. Fetus palpated to be in left occiput posterior position

and large by Leopold's movements. Head fixed in pelvis. FHR: 150 beats per minute.

Pelvic Examination: Diagonal conjugate measured at 12 cm. Pubic arch wide; ischial

diameter: 12 cm; coccyx movable. Cervical dilation: 4 cm; effacement: 20%. Station: 0.

Bishop Score: 9

Extremities: Unremarkable.

CARE STUDY QUESTIONS:

1. Molly is worried she is having a dysfunctional labor. This is

a. labor contractions that serve no function.

b. contractions that are more painful than usual.

c. labor that is prolonged or ineffective.

d. labor that is unusually short in length.

Answer: c. Dysfunctional labor is prolonged or ineffective labor, usually resulting from

hypotonic contractions.

2. If contractions are hypertonic, their resting tone will be above average. A usual

resting tone is

a. 5 mm Hg.

b. 15 mm Hg.

c. 25 mm Hg.

d. 45 mm Hg.

Answer: b. A normal resting tone is 15 mm Hg.

3. The danger of a resting tone that is too high is that

a. newborns are born tense or irritated from lack of rest.

b. the woman becomes intoxicated with breakdown products.

c. amniotic fluid increases in amount from poor fetal swallowing.

d. lack of relaxation prevents optimal uterine artery filling.

Answer: d. It is important that uterine arteries fill between contractions to supply enough

oxygen to the fetus.

4. The length of the usual second stage of labor for a nullipara is

a. ½ hour.

b. 1 hour.

c. 3 hours.

d. 5 hours.

Answer: b. The second stage of labor is short related to the first stage. As long as descent

is occurring, there is no set length that is optimal.

5. Formation of a pathologic contraction ring is a danger sign of labor. To assess for this,

you would

a. observe the contour of Molly’s abdomen.

b. palpate her lower uterus for a spongy feel.

c. auscultate her abdomen for “pinging” sounds.

d. palpate her cervix vaginally for softness.

Answer: a. A contraction ring appears as a horizontal indentation across the woman’s

abdomen.

6. Uterine rupture is a serious complication of labor. Which factor in Molly’s history

makes her high risk for uterine rupture?

a. Her fetus is in an occipitoposterior position.

b. She is over 21 years of age.

c. She is asking for something for pain relief.

d. She has not eaten since she started labor.

Answer: a. Molly’s fetus is in a posterior position. A previous cesarean birth, multiple

birth, prolonged labor, oxytocin induction, and an abnormal presentation are all risks for

uterine rupture.

7. Which of the following would be a sign that uterine rupture has occurred?

a. A sudden blood pressure increase or “spike”

b. Sharp abdominal pain in between contractions

c. Leek of amniotic fluid from the vagina

d. Bleeding from an IV or intramuscular site

Answer: b. If a uterus tears (ruptures), the woman first feels sharp pain. Bleeding will be

within the uterus but may be external if the cervix is dilated.

8. Placenta accreta can cause a complication of labor. When this occurs, the

a. umbilical cord will not deliver.

b. umbilical vein develops aneurysms.

c. placenta is unusually deeply attached.

d. placenta delivers before the membranes.

Answer: c. A placenta accreta is one unusually deeply attached so it can not be readily

removed without hemorrhage occurring. Methotrexate may be prescribed to help destroy

the remnants of the still-attached placenta.

9. What if Molly’s doctor suggests she deliver her baby by vacuum extraction? Which

condition below in her history would make you question whether this technique is

appropriate for her?

a. Her baby is immature.

b. Molly had a STD in high school.

c. This is Molly’s third pregnancy.

d. Molly plans to breastfeed.

Answer: a. Molly’s pregnancy is only 37 weeks. An immature fetal skull is softer than

normal so it might be harmed by the vacuum pressure.

10. If a fetus is in a breech position, it can be turned to a cephalic position by external

cephalic version just before or during labor. An important assessment to make

immediately following this would be

a. abdominal contour.

b. bladder emptying.

c. fetal heart rate.

d. rectal bleeding.

Answer: c. Assessing the fetal heart rate would assure the fetal cord was not compressed

by the maneuver.

11. Molly has been given pitocin, which has begun to strengthen uterine contractions.

What classification of drug is pitocin?

a. Estrogen
b. Prostaglandin

c. Dopamine inhibitor

d. Oxytocic

Answer: d. Pitocin is oxytocin. An oxytocic is a drug that initiates or maintains uterine

contractions.

12. The degree of Molly’s cervix ripening is rated as 9 on a Bishop Scale. Based on this,

you would

a. encourage her to take deep breaths to increase cervical softening.

b. rate her as an acceptable person to have oxytocin induction.

c. alert her M.D. that her cervix is still too immature for oxytocin.

d. infuse the oxytocin at half the prescribed rate until the scale is 12.

Answer: b. A score of 8 to 10 indicates a cervix is “ripe” or soft and ready for dilation.

13. Suppose Molly has prostaglandin E2 applied to her cervix to increase cervical

ripening before labor. Side effects of this drug for which you would assess include

a. pain on neck flexion.

b. pain in the calf of her leg.

c. severe hypertension.

d. rectal bleeding.

Answer: c. Hypertension, diarrhea, vomiting, and fever are all common side effects of

prostaglandin E2 cervical application.

14. What is a good technique to follow when infusing oxytocin to ensure safe

administration during labor?

a. Begin the infusion as a “piggyback” to a primary IV solution.

b. Be sure dye is added to the infusion so it shows on sonogram.

c. Do not use an infusion pump to not crush the oxytocin crystals.

d. Infuse the total solution over 1 hour to prevent it from “aging.”

Answer: a. Piggybacking allows you to immediately discontinue oxytocin if contractions

become too frequent or too intense. Always use a pump to decrease the possibility of

oxytocin overdose.

15. A side effect of oxytocin administration is water intoxication. A signal that this is

occurring for which you would assess is

a. hypotension or BP below 100/60.

b. “burping” following swallowing.

c. headache and mental confusion.

d. urine flow increased to 1000 mL/h.

Answer: c. Water intoxication means fluid is pooling in interstitial spaces. This increased

tension leads to headache and vomiting and mental confusion. Urine flow would be

decreased.

16. Molly’s baby is large, which means the baby is at risk for shoulder dystocia. Which

finding in the newborn would be most important to assess for following shoulder

dystocia in labor?
a. Blue tinged toes and fingers

b. Bleeding at the cord site

c. Open shoulder lesions

d. Uncoordinated respirations

Answer: d. As the newborn’s head is bent to the side to help deliver the wide shoulders,

the diaphragmatic nerve may be injured. This leads to uncoordinated respiratory

movements.

17. If a fetus is determined to be a face presentation, what would be most important to

observe for in the newborn after birth?

a. Decreased hearing

b. Signs of dehydration

c. Corneal irritation

d. Sinus congestion

Answer: b. The baby's face is extremely edematous following birth, so much so that

sucking can be ineffective.

18. Labor is said to be precipitous if

a. the total length is under 3 hours.

b. it occurs outside a hospital or birth center.

c. the woman was not prepared for birth.

d. anesthesia relaxed the cervix too much.

Answer: a. A labor under 3 hours is precipitous; such labors can be so abrupt that a fetus

experiences sudden pressure changes to the head, possibly resulting in tearing of cranial

vessels.

19. Amniotic fluid embolism is a potential complication of labor. Which statement below

is true regarding this?

a. If it occurs, the amniotic fluid will appear bloody.

b. The woman will experience sharp uterine pain.

c. It is an emergency and can lead to pulmonary embolus.

d. Vaginal bleeding will occur to signal the event.

Answer: c. Amniotic embolism means amniotic fluid has entered the maternal

bloodstream. This can cause a pulmonary embolism that could be fatal.

20. Suppose Molly’s baby is a forceps birth. Although rarely used today, the advantage of

a forceps birth can be that

a. total labor is shortened to less than 1 hour.

b. less pressure may be exerted on the fetal head.

c. cervical ripening does not have to occur.

d. the baby can be turned to a breech position.

Answer: b. When forceps are applied, pressure is exerted on the forceps, not the fetal

head.