Study sets, textbooks, questions
Upgrade to remove ads
Labor and Birth Complications
Terms in this set (201)
Cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy. Caused by multiple pathologic processes that eventually result in uterine contractions, cervical changes, and membrane rupture.
Any birth that occurs before the completion of 37 weeks of pregnancy, regardless of birth weight.
Occur between 34 and 36 weeks gestation. At increased risk for early death and long-term health problems when compared with infants who are born full term.
Very preterm birth
Born before 32 weeks gestation, most serious morbidity.
Common causes of indicated preterm birth
Pre-existing or gestational diabetes, chronic hypertension, preeclampsia, obstetrical disorders or risk factors in the current or a previous pregnancy, previous c-section via a classic uterine incision, placental disorders, medical disorders (seizures, thromboembolism, maternal HIV or herpes infection, obesity), advanced maternal age, fetal disorders (chronic IUGR or acute NST or BPP fetal compromise, excessive or inadequate amount of amniotic fluid, birth defects)
Risk factors for spontaneous preterm labor
Hx of previous spontaneous preterm birth, african-american race, genital tract infection, multifetal gestation, second-trimester bleeding, low prepregnancy weight, poverty, lack of education, living in disadvantaged neighborhood, state, or region, lack of access to prenatal care. 50% of all women ultimately give birth prematurely have no identifiable risk factors
Preterm birth VS LBW
Preterm birth is a more dangerous health condition for an infant because less time in the uterus correlates with immaturity of body systems. LBW can be, but not necessarily, preterm. Can be caused by intrauterine growth restriction (IUGR).
Intrauterine growth restriction (IUGR)
Condition of inadequate fetal growth not necessarily correlated with initiation of labor. Can be caused by complications that interfere with uteroplacental perfusion (gestational hypertension, poor nutrition)
Two types of preterm birth
Spontaneous and indicated.
Spontaneous preterm birth
Occurs after an early initiation of the labor process and comprises nearly 75% of all preterm births. Intact membranes, preterm premature rupture of membranes, cervical insufficiency, amnionitis.
Indicated preterm birth
Occurs as a means to resolve maternal or fetal risk related to continuing pregnancy. Medical or obstetric conditions that affect mother, fetus, or both. 34-36 weeks.
Fetal Fibronectin Test
Biochemical marker, diagnostic test for preterm labor. Glycoprotein "glue" found in plasma and produced during fetal life. Normally appears in cervical and vaginal secretions early in pregnancy, then late in pregnancy. Collecting fluid from woman's vagina using swab during speculum exam. Presence during late second and early third trimester: may be related to placental inflammation, thought to be cause of spontaneous preterm labor. Not very sensitive as a predictor of preterm birth. Negative result: unlikely to go into preterm labor.
Another possible predictor. Changes occur before uterine activity, so measurement can identify women in the labor process. NOt very sensitive. Greater than 30 mm: unlikely to give birth prematurely even if having symptoms of it
Infection and Preterm labor
Intact membranes in spontaneous preterm labor commonly have organisms normally found in lower genital tract present in amniotic fluid, placenta, and membranes. UTI and intraabdominal infections have been related to preterm birth. Women with periodontal disease increased risk for preterm birth.
Bleeding at Implantation in uterus in first or second trimester and preterm labor
Resulting uteroplacental ischemia or hemorrhage at decidual layer of placenta may somehow activate preterm labor process. Intrauterine inflammation associated infection, uterine vascular compromise, and decidual hemorrhage and may contribute to preterm labor. Maternal and fetal stress, uterine overdistention, allergic reaction, decrease in progesterone.
Prophylactic progesterone supplementation
Preterm birth can be prevented in some women by administering it. Daily vaginal suppositories or creams and weekly intramuscular injections have been shown to decrease rate of preterm birth in women with a hx of preterm birth or short (less than 15-20 mm) cervix before 24 weeks gestation. Not with multiple gestations.
Interventions in preterm labor
Transfer mother to hospital equipped for preterm infant, antibiotics to prevent group B strep infection, administer glucocorticoids to prevent or reduce infant morbidity/mortality, administer magnesium sulfate to women giving birth before 32 weeks of gestation to reduce incidence of CP in infants
Symptoms of Preterm Labor
Uterine activity: contractions occurring more frequently than every ten minutes persisting for 1 hour or more, uterine contractions may be painful or painfulness.
Discomfort: lower abdominal cramping, dull, intermittent low back pain (below waist), painful, menstrual like cramps, suprapubic pain or pressure, pelvic pressure or heaviness, urinary frequency.
Vaginal discharge: change in character or amount of usual discharge (thicker or thinner), bloody, brown or colorless, increased amount, odor, rupture of amniotic membranes
Maternal interventions if symptoms of preterm labor occur
Empty bladder, drink 2-3 glasses of water or juice, lie down on side for 1 hour, palpate for contractions. Symptoms continue: call HCP or go to hospital. If go away: resume light activity. Return: call HCP, go to hospital. Hospital immediately: uterine contractions every 10 minutes or less for 1 hour or more, vaginal bleeding, fluid leaking from vagina
Diagnosis of preterm labor
Gestational age between 20-37 weeks, uterine activity (contractions), progressive cervical change (effacement of 80% or cervical dilation of 2 cm or greater). Misdiagnosis: inappropriate use of pharmacological agents that can be dangerous to health of woman, fetus, or both
Bed rest and limited work is commonly prescribed intervention for prevention of preterm birth. Benign intervention, no evidence to support effectiveness. Can have adverse physical effects.
Adverse effects of bed rest (maternal physical)
Weight loss, indigestion, loss of appetite, muscle wasting, weakness aching muscles, bone demineralization and calcium loss, decreased plasma volume and CO, increased clotting tendency, risk for thrombophlebitis, cardiac deconditioning, alteration in bowel function, sleep disturbance, fatigue, prolonged postpartum recovery
Maternal Adverse Effects of bed rest (psychosocial)
Loss of control associated with role reversals, dysphorias (anxiety, depression, hostility, and anger), guilt associated with difficulty complying with activity restriction and inability to meet role responsibilities, boredom, loneliness, emotional lability (mood swings), difficulty concentrating, increased stress
Adverse effects of bed rest on support system
Stress associated with role reversals, increased responsibilities, and disruption of family routines, financial strain, fear and anxiety
Restriction of sexual activity
Frequently recommended for women at risk for preterm birth. Not been shown to be effective. If symptoms of preterm labor occur after sexual activity, should abstain
Modified bed rest
Bathroom privileges, up to table for dinner
Medications given to arrest labor after uterine contractions and cervical change have occurred. No FDA approved drugs are available in US. Ritodrine (Yutopar) approved but withdrawn from market. "Off-label" basis (drugs known to be effective for specific purpose, although not specifically developed and tested for this purpose). Used to delay birth long enough to allow time for maternal transport and for corticosteroids to reach maximum effect.
Inhibits uterine contractions and decreases intracellular calcium levels. IV. Few serious maternal or neonatal complications. Recently found not to be effective tocolytic. Depresses function of CNS, essential that nurse assess respiratory status, deep tendon reflexes, LOC
Beta2 Adrenergic agonists
Widely used in past as tocolytics. Many maternal and fetal side effects: cardiopulmonary effects, metabolic effects. Not used widely, not used in women with heart disease, preeclampsia or eclampsia, diabetes, hyperthyroidism, migraines
Most commonly administered beta-adrenergic agonist used for tocolysis in US. Relaxes uterine smooth muscle. Subcutaneous 1 dose: help diagnose preterm labor. Contractions persist or recur after a single injection are more likely to be in actual preterm labor. May also be given to suppress uterine tachysystole during labor induction, augmentation, or suppress contractions after c-section.
Contraindications to tocolytic therapy
Maternal: severe preeclampsia or severe gestational hypertension, significant vaginal bleeding, cardiac disease
Fetal: gestational age of 37 weeks or more, fetal demise, lethal fetal anomaly, chorioamnionitis, evidence of acute or chronic fetal compromise
Nursing care of tocolytic therapy
Position on side to enhance placental perfusion and reduce pressure on cervix, monitor maternal VS, lung sounds and resp effort, FHR and pattern, labor status, signs of adverse reactions, maternal fluid balance (I and O), limit fluid intake to 2500-3000 mL a day, esp w/ beta-adrenergic or magnesium sulfate
Calcium channel blocker that can suppress contractions. Inhibits calcium from entering smooth muscle cells, reducing uterine contractions. Low incidence of maternal and fetal side effects, use is increasing. Side effects: headache, flushing, dizziness, nausea (mild). Follow recommended dosages, avoid concurrent use of magnesium sulfate, maintain maternal BP
Nifedipine and magnesium sulfate
Can cause skeletal muscle blockade
Calcium channel blocker and orthostatic hypotension
Slowly change position from supine to upright, sit before standing until dizziness disappears, maintain adequate fluid balance to reduce drop in BP
NSAID, shown to suppress preterm labor, serious maternal side effects uncommon, well tolerated. Three serious fetal side effects: constriction of ductus arteriosus, oligohydramnios, neonatal pulmonary HTN. Limiting use to short duration of tx especially less than 32 weeks gestation.
Given intramuscular injections to mother to accelerate fetal lung maturity by stimulating fetal surfactant production. One of most effective and cost-efficient interventions for preventing morbidity and mortality associated with preterm labor. Significantly reduce incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death in neonates without increasing risk for infection. In general, women who are candidates for tocolytic therapy also candidates for antenatal glucocorticoids (24-34 weeks).
Inevitable Preterm Birth
Magnesium sulfate to reduce or prevent neonatal neurologic morbidity (CP) for 24-32 weeks gestation at time birth expected to occur. 4 cm or more likely to lead to birth. Very small fetus may be born through partially dilated cervix. Malpresentation can occur much more frequently in preterm. Equipment, supplies, and medications used for neonatal resuscitation should be gathered
Fetal and Early Neonatal Loss
Preterm, congenital anomalies, genetic disorders incompatible with death measure reasons for intrauterine fetal demise (stillbirth) or early neonatal death. May be expected or unexpected. If expected: discuss before birth, management plan. FHR not monitored. Decision: whether to attempt neonatal resuscitation, what lengths. Too small, too immature, too malformed for effective resuscitation: comfort care provided. Can choose to view or hold baby if wish. Can choose to stay on unit or be moved.
Premature rupture of membranes (PROM)
Spontaneous rupture of the amniotic sac and leakage of amniotic fluid beginning before onset of labor at any gestational age.
Preterm premature rupture of membranes (preterm PROM)
Membranes rupture before completion of 37 weeks gestation. Most likely results from pathologic weakening of the amniotic membranes caused by inflammation, stress from uterine contractions, or other factors that cause increased intrauterine pressure. Infection of urogenital tract major risk factor associated with preterm PROM.
Risk Factors for Preterm ROM
History of prior preterm birth, especially preterm ROM, hx of cervical conization or cerclage, urinary or genital tract infection, short cervical length in 2nd trimester, preterm labor in current pregnancy, uterine overdistention, second and third trimester bleeding, pulmonary disease, connective tissue disorders, low socioeconomic status, low BMI, nutritional deficiencies (copper and ascorbic acid), cigarette smoking
Most common maternal complication of preterm PROM, major complication of pregnancy. Bacterial infection of the amniotic cavity, 1-5% of term births, 25% of preterm births. Diagnosed: clinical findings of maternal fever, maternal and fetal tachycardia, uterine tenderness, foul odor of amniotic fluid. Most often occurs after membranes rupture or labor begins, as organisms are part of the normal vaginal flora ascend into amniotic cavity. Risk factors: long labor (prolonged membrane rupture, multiple vaginal examinations, use of internal FHR and contraction monitoring). Other risk factors: young maternal age, low socioeconomic status, nulliparity, preexisting infections of lower genital infection
Serious maternal complications of Preterm PROM
Placental abruption, retained placenta and hemorrhage requiring dilation and curettage (D&C), sepsis, and death.
Fetal complications from preterm PROM
Related primarily to intrauterine infection, cord prolapse, umbilical cord compression associated with oligohydramnios, and placental abruption. Before 20 weeks gestation: pulmonary hypoplasia
Term and Infection
Birth best option, infection is greatest maternal, fetal, and neonatal risk. Induced if birth not spontaneous after PROM occurs
Occurring at or after 23 weeks gestation, managed conservatively if risks to fetus and newborn associated with preterm considered to be greater than risks of infection. Hospitalized in attempt to prolong pregnancy, additional time for fetal maturation, unless intrauterine infection, significant vaginal bleeding, placental abruption, advanced labor, non-reassuring fetal assessment,
Conservative management of preterm PROM
Fetal assessment by nonstress test (NST) and biophysical profile (BPP) at least daily. Woman taught how to assess fetus using daily fetal movement counts (DFMC), slowing of fetal movement shown to be precursor to severe fetal compromise. Monitored for signs of labor, placental abruption, development of intrauterine infection. Antenetal glucocorticoids: administered less than 32 weeks gestation. 7 day course of broad spectrum antibiotics will be administered.
Signs of Infection after preterm PROM
Part of nursing care and patient education. Keep genital area clean, nothing introduced into vagina.Fever, foul-smelling vaginal discharge, maternal and fetal tachycardia reported immediately. Chorioamnionitis: labor should be induced. Preterm labor: tocolytic meds to gain time for transporting women to hospital capable of providing care to preterm infant or for antenatal corticosteroids or antibiotics to reach effective levels.
Consequences of chorioamnionitis
Can develop bactremia. More likely to have dysfunctional labor, which can result in c-section. Wound infection or pelvic abscess, possible complication. Neonatal risks: pneumonia, bactremia, and sepsis. Death more likely to occur in preterm than in term infants. Association between chorioamnionitis and long-term neurologic development in newborn, including CP. Prompt intervention with broad-spectrum antibiotics and birth of fetus necessary.
Postdate or prolonged pregnancy, extends beyond end of week 42 of gestation, or 294 days from first day of the last menstrual period (LMP). Use of LMP alone for pregnancy dating tends to greatly overestimate number of postterm gestations. More common in prmiparous women, a woman who experiences one postterm pregnancy is more likely to experience it again in subsequent pregnancies. Perinatal morbidity increases greatly after 42 weeks gestation
Postterm Pregnancy Clinical Manifestations
Maternal weight loss (more than 3 lbs/wk) and decreased uterine size (related to decreased amniotic fluid), meconium in amniotic fluid, advanced bone maturation of fetal skeleton with an exceptionally hard fetal skull
Postterm Maternal Risks
Often related to dysfunctional labor, increased risk for perineal injury related to fetal macrosomia. Risk for hemorrhage, infection higher. Induction of labor (prostaglandins or oxytocin), forceps- or vacuum-assisted birth, cesarean birth more likely to be necessary.
Postterm Fetal Risks
Abnormal fetal growth. Small-for-gestational age increased, only some born undernourished. Macrosomia occurs more often.
Birth weight more than 4000 g. Occurs when placenta continues to provide adequate nutrients to support fetal growth after 40 weeks of gestation. Increased risk for birth injuries caused by forceps-assisted births and shoulder dystocia. 43-44 weeks of gestation: placenta begins to age. Enlarging areas of infarction, increased deposition of calcium and fibrin in its tissue decrease placenta's reserve and may affect its ability to oxygenate fetus. Maternal DM, obesity, multiparity, large size of one or both parents
Decreased amniotic fluid (less than 400 mL) is most frequently associated with postterm pregnancy. Potential cord compression and resulting hypoxemia. Magnifies effect of meconium staining, not enough to dilute it makes meconium thicker and stickier than it would otherwise be
Potential complications of Macrosomia
Meconium-stained amniotic fluid, increased chance of meconium aspiration, low Apgar scores
20% of neonates born after postterm pregnancies. Characterized by dry, cracked, peeling skin, long nails, meconium staining of skin, nails, and umbilical cord; and perhaps loss of subcutaneous fat and muscle mass
Inducing labor/twice weekly fetal testing
Most induce labor at 41 weeks gestation. Or initiate twice-weekly fetal testing at 41 weeks gestation (BPP or NST, assessment of amniotic fluid volume aka modified BPP).
Postterm in labor
Fetus should be continually monitored electronically for more accurate assessment of FHR and pattern. Inadequate fluid volume can lead to compression of umbilical cord, results in fetal hypoxia that is reflected in variable or prolonged deceleration patterns.
If oligohydramnios present, may be performed to restore amniotic fluid volume to maintain a cushioning of the cord.
Dysfunctional Labor (dystocia)
Long, difficult, or abnormal labor caused by various conditions associated with five factors affecting labor: ineffective uterine contractions or maternal bearing down efforts (powers) alterations in pelvic structure (passage), fetal causes (abnormal presentation or position, anomalies, excessive size, and number of fetuses- passenger), maternal position during labor and birth, psychologic responses of mother to labor. Alteration in characteristics of uterine contractions, lack of progress in rate of cervical dilation, lack of progress in fetal descent and expulsion
Increase woman's risk for dysfunctional labor
Overweight, short stature, advanced maternal age, infertility difficulties, prior version, masculine characteristics, uterine abnormalities (congenital malformations, overdistention, as with multiple gestation, polyhydraminos), malpresentation and positions of fetus, cephalopelvic disproportion (CPD), fetopelvic disproportion FPD), uterine overstimulation with oxytocin, maternal fatigue, dehydration and electrolyte imbalance, and fear, administration of analgesic medication too early in labor or use of continuous epidural analgesia
Abnormal Uterine Activity
Hypertonic or hypotonic.
Hypertonic Uterine Dysfunction
Primary dysfunctional labor, often anxious first-time mother having painful and frequent contractions that are ineffective in causing cervical dilation or effacement progress. Usually latent phase of first stage labor (less than 4 cm), usually uncoordinated. May be in midsection rather than fundus, may not relax completely between contractions. Exhausted, loss of control, intense pain, lack of progress. Therapeutic rest (warm bath or shower, morphine). Ambien may be used to facilitate sleep. After rest more likely to awaken in active labor with normal uterine contraction pattern
Hypotonic uterine dysfunction
More common type, aka secondary uterine inertia. Initially makes normal progress into active phase of first-stage labor but then contractions become weak and inefficient or stop altogether. Uterus easily indented, even at peak of contractions. Intrauterine pressure (IUP) during contraction is insufficient for progress of cervical effacement and dilation. CPD, malposition common causes. May be exhausted, increase risk for infections. R/O CPD, assess FHR and pattern, characteristics of amniotic fluid if membranes ruptured, maternal well-being. IUPC evaluate UA accurately. Normal: labor augmentation measures
Bearing-down efforts, compromised when large amount of analgesic meds given. Anesthesia may also block. Exhaustion reduces effectiveness, maternal position can work against gravity
Hypertonic uterine dysfunction factors (primary powers)
Before 4 cm dilation, cause unknown, fear or tension maybe. Pain out of proportion to intensity of contractions in effacing and dilating cervix, contractions increase in frequency, uncoordinated, uterus contracted between contractions. Fetal asphyxia with meconium aspiration is a risk. Initiate therapeutic rest, administer analgesic if membranes intact and pelvic adequacy confirmed, relieve pain to permit mother to rest, assist with measure to enhance rest and relaxation
Hypotonic Uterine Dysfunction Factors (primary powers)
Cause usually cephalopelvic disproportion or fetal malposition. Contractions decrease in frequency and intensity, uterus easily indented even at peak of contractions, uterus relaxed between contractions (normal). Maternal effects: infection, exhaustion, stress. Fetal effects: infection, death. Care: r/o cephalopelvic disproportion, augment labor with oxytocin, perform amniotomy, assist with measures to enhance progress of labor
Inadequate voluntary expulsive forces
Involves abdominal and levator ani muscles, occurs in second stage of labor, cause may be related to nerve block anesthetic, analgesia, exhaustion, no voluntary urge to push or bear down or inadequate or ineffective pushing, spontaneous vaginal birth prevented (assisted birth likely), fetal asphyxia, coach mother in bearing down with contractions, assist with relaxation between contractions, position mother in favorable position for pushing, reduce epidural infusion rate, assist with forceps or vacuum-assisted birth, prepare for c-section if abnormal fetal status occurs
Abnormal Labor Patterns
Six abnormal labor patterns: prolonged latent phase, protracted active-phase dilation, secondary arrest (no change), protracted descent, arrest of descent, failure of descent. Variety of causes (ineffective uterine contractions, pelvic contractures, CPD, abnormal fetal presentation or position, early use of analgesics, nerve block analgesia or anesthesia, anxiety and stress.
Protracted abnormal labor patterns
Progress in either first or second stage of labor can be prolonged or arrested (stopped).
Abnormal progress can be identified by plotting cervical dilation and fetal descent on this labor graph at various intervals after onset of labor and comparing resulting curve with expected labor curve for nulliparous or multiparous labor. Abnormal pattern: HCP notified.
Maternal and fetal risks: dysfunctional labor
Morbidity and mortality from uterine rupture, infection, severe dehydration, postpartum hemorrhage are higher in women experiencing dysfunctional labor. Fetus: increase risk for hypoxia.
Lasts less than 3 hours from onset of contractions to time of birth. Abnormal. Usually not associated with significant maternal or infant morbidity or mortality if no other factors. May result from hypertonic uterine contractions and associated with placental abruption, uterine tachysystole, recent cocaine use.
Maternal complications of Precipitous Labor
Uterine rupture, lacerations of birth canal, amniotic fluid embolus (anaphylactoid syndrome of pregnancy), and postpartum hemorrhage.
Fetal complications of Precipitous Labor
Shoulder dystocia, hypoxia caused by decreased periods of uterine relaxation between contractions, intracranial trauma r/t rapid birth
Prolonged Latent phase
Abnormal labor pattern. Longer than 20 hours in nulliparas, longer than 14 hours in multiparas.
Protracted active phase dilation
Abnormal labor pattern. Less than 1.2 cm per hour in nulliparas, less than 1.5 cm per hour in multiparas
Secondary arrest: no change
Abnormal labor pattern. Greater or equal to 2 hours in nulliparas and multiparas
Abnormal labor pattern. Less than 1 cm per hour in nulliparas, less than 2 cm per hour in multiparas.
Arrest of descent
Abnormal labor pattern. Greater than or equal to 1 hour in nulliparas, greater than or equal to 1/2 hour in multiparas
Failure of descent
Abnormal labor pattern. No change during deceleration phase and second stage
Precipitous Labor Values
Abnormal labor pattern. Greater than 5 cm/hour in nulliparas, 10 cm/hour in multiparas
Occur when contractures of pelvic diameters exist that reduce capacity of bony pelvis (inlet, midpelvis, outlet). Contractures: may be caused by congenital abnormalities, maternal malnutrition, neoplasms, lower spinal disorders. Immature pelvic size predisposes some adolescent mothers. Can be result of trauma
Obstruction of birth passage by an anatomic abnormality other than that involving bony pelvis. Placenta previa (low lying placenta), that partially or completely obstructs internal cervical os. Other causes: leiomyomas (uterine fibroids), ovarian tumors, full bladder or rectum, cervical edema when cervix caught between presenting part and symphysis pubis or women begins bearing down efforts prematurely. STIs.
Fetal causes of dystocia
Anomalies, macrosomia, malpresentation, malposition, multifetal pregnancy. Complications: neonatal asphyxia, fetal injuries or fractures, maternal vaginal lacerations. Assisted birth often necessary
Anomalies of Fetus (Dystocia)
Gross ascites, open neural tube defects, hydrocephalus. Affect relationship of fetal anatomy to maternal pelvic capacity
Cephalopelvic Disproportion (CPD) (Dystocia)
Also called fetopelvic disproportion (FPD), disproportion between size of fetus and size of mother's pelvis. Fetus cannot fit through maternal pelvis to be born vaginally. Macrosomia or malposition of presenting part. Maternal pelvis too small, abnormally shaped, deformed.
Most common fetal malposition is persistent occipitoposterior position. Labor in second stage prolonged. Complains of severe back pain
Fetal presentation is something other than head first. Breech most common form. Transverse lie (shoulder) presentation- c-section necessary.
Three types of breech presentation
Frank breech (hips flexes, knees extended), Compete breech (hips and knees flexed), Footling Breech (one foot- single, or both feet-double present before buttocks)
Associated with multifetal gestation, preterm birth, fetal and maternal anomalies, hydramnios, and oligohydraminos. Neuromuscular disorders have high rate of breech presentation. Abnormal amniotic fluid volume contributes because it can affect fetal mobility. Diagnosed with abdominal palpation (leopold maneuvers) and vaginal examination, ultrasound scan
Breech presentation may be slow because it is not as effective a dilating wedge as the head. Risk for prolapse of cord if membranes rupture in early labor. Meconium in fluid: not necessarily sign of distress, pressure on abdominal wall. Assessment of FHR and pattern to determine whether passage of meconium is expected finding or abnormal sign of hypoxia. C-section indicated if presentation persists, fetal distress occurs, labor stops progressing.
Fetal heart tones (FHTs) in breech position
Heard best at or above the umbilicus
Vaginal birth breech
Mechanisms of labor that manipulate buttocks and lower extremities as emerge from birth canal. Risks: prolapse of umbilical cord (especially with footling), trapping or after-coming fetal head (especially with preterm infants). Criteria for attempting vaginal birth: frank or complete breech presentation, estimated fetal weight between 2000-3800 g, normal (gynecoid) maternal pelvis, flexed fetal head. Forceps often used, spontaneous possible if flexes to vertex presentation.
Two or more infants. Multiple births associated with more complications than single births. higher incidence of fetal and newborn complications and higher risk for perinatal mortality stem primarily from birth of LBW resulting from preterm birth or IUGR (or both), placental dysfunction and twin-to-twin transfusion. Distress and asphyxia during birth process as result of cord prolapse, onset of placental separation with birth of first fetus. Fetal complications: congenital anomalies, abnormal presentations result in dysfunctional labor, increased c-sections. Oxytocin, epidural, internal or external version, forceps and vacuum may be used to vaginally deliver.
Position of Mother
Relationship among contractions, fetus, pelvis altered by maternal position. Can provide advantage or disadvantage to mechanisms of labor by altering effects of gravity.
When anxiety is excessive, can inhibit cervical dilation, result in prolonged labor and increased pain perception. Anxiety=increased stress hormones that act on smooth muscle of uterus, reducing uterine contractility
Labor and Birth Complications
Document all assessment findings, interventions, woman's responses in record, assess whether woman and family fully informed about procedures consenting for, provide full explanation on what is happening and needs to be done, maintain safety in administering meds and txs, telephone orders singed as soon as possible, provide care at acceptable standard, document short staffing, continue maternal and fetal monitoring until birth
Ongoing process. Review past labor or labors and observe physical and psychologic responses to current one. Factors that may contribute to dysfunctional labor should be identified.
Likely to begin pregnancy with pre-existing medical conditions (diabetes, hypertension). May develop pregnancy -associated hypertensive disorders or gestational diabetes. Increased incidence of postdates pregnancy. Increased risk for c-section and emergency c-section. BMI increases, risk for complications increases. Risk for thromboembolism and wound disruption and infection after c-section.
Considerations with obese
External FHR and contraction monitoring difficult if not impossible to perform. IV access difficult, mobility problem, difficulty establishing an epidural or spinal block, accomplished endotracheal intubation. Postop: increased risk for blood clot formation (TED hose, SCD), heparin for clot prevention. Get out of bed and ambulate asap. Keep incision clean, dry, prevent wound infection, promote healing is challenging. Pannus overlies lower abdominal transverse skin incision made just above pubic area. Causes area to remain moist.
Large roll of abdominal fat.
Turning of the fetus from one presentation to another. Externally or internally by physician
External Cephalic Version (ECV)
Used in an attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth. Attempted in labor and birth setting after 37 weeks gestation. Exertion of gentle, constant pressure on the abdomen. Before ECV: determine fetal position, locate umbilical cord, rule out placenta previa, evaluate maternal pelvis, assess amount of amniotic fluid, gestational age, presence of any anomalies. NST: confirm fetal well-being, FHR and pattern monitored for period of time. Tocolytic agent to relax uterus. Sometimes under regional anesthesia. Most successful in multiparous woman who has normal amount of amniotic fluid and fetus is not yet engaged in pelvis.
Contraindications to ECV
Uterine anomalies, third-trimester bleeding, multiple gestation, oligohydramnios, evidence of uteroplacental insufficiency, a nuchal cord (identified by ultrasound), previous c-section or other significant uterine surgery, obvious CPD
Nurses' role during ECV
Continuously monitor FHR and pattern, especially bradycardia and variable decelerations; checks maternal VS; assess woman's level of comfort because procedure may cause discomfort. After: continue to monitor maternal VS and UA, assess for vaginal bleeding until stable, FHR and pattern monitoring should continue for at least 1 hour. Rh negative: should receive Rh immune globulin because manipulation can cause fetomaternal bleeding
Turned by physician who inserts hand into uterus and changes presentation to cephalic (head) or podalic (foot). Rarely used, most often in twin gestations to assist with birth of second fetus, maternal and fetal injury are possible. C-section: malpresentation in multifetal pregnancies. Nurse's role: monitor status of fetus and provide support to woman
Induction of Labor
Chemical or mechanical initiation of uterine contractions before spontaneous onset for purpose of bringing about birth. Electively or indicated reasons. Indicated if continuing pregnancy could be dangerous for either the woman or fetus and if no contraindications exist to artificial rupture of membranes or augmenting uterine contractions with oxytocin. Informed consent: fully counseled regarding risks, benefits, alternatives
Indications for Labor Induction
Hypertensive complications of pregnancy (gestational HTN, preeclampsia, eclampsia), fetal death, chorioamnionitis, maternal medical conditions (DM, renal disease, cardiopulmonary conditions, chronic HTN, antiphospholipid syndrome), postterm pregnancy (esp with oligohydramnios present), fetal compromise (IUGR, isoimmunization), premature rupture of membranes with established fetal maturity
Contraindications for Labor Induction
Acute, severe fetal distress, shoulder presentation (transverse lie), floating fetal presenting part, uncontrolled hemorrhage, umbilical cord prolapse, active genital herpes infection, placenta previa, previous uterine incision that prohibits trial of labor
Relative Contraindication for Labor Induction
Grand multiparity (more than 5 pregnancies that ended after 20 weeks gestation), multiple gestation, suspected cephalopelvic disproportion, breech presentations, inability to adequately monitor FHR or contractions (or both) throughout labor
Elective induction of labor
Without medical indication. Methods to ripen cervix (prostaglandins or intracervical insertion of balloon catheter) enhances likelihood of successful induction. Convenience. Allay fears and anxieties, ensure experienced personnel available to handle anticipated maternal or neonatal complications. Major risk: increased rates of c-section, neonatal morbidity, cost. Not be initiated until 39 weeks or more of gestation. Intravenous oxytocin (pitocin) and amniotomy most common methods in US. Cervical ripeness most important predictor of successful induction.
Used to evaluate inducibility. 8 or more, induction usually successful. Should be documented before use of methods to ripen cervix or induce labor. Score 0-3 on dilation (0, 1-2, 3-4, 5 or above), effacement (0-30, 40-50, 60-70, 80 or above), station (-3, -2, -1/0, +1/+2), cervical consistency (firm, medium, soft, soft), cervical position (posterior, midposition, anterior, anterior).
Chemical agents of cervical ripening
Prostaglandins to ripen (soften and thin) the cervix. Can spontaneously begin laboring without need for oxytocin, decreased amount, decreased induction time. PGE1: cheaper, more effective, more side effects. PGE2: more expensive, easy removal (safer)
Mechanical and Physical Dilators
Ripens cervix by stimulating release of endogenous prostaglandins. Balloon catheters (Foley) can be inserted through the intracervical canal to ripen and dilate cervix. Pressure and stretching of lower uterine segment and cervix, release of endogenous prostaglandins. Safe and cheap. Less likely to cause uterine tachysystole.
Substances that absorb fluid from surrounding and then enlarge. Laminaria tents (desiccated seaweed) and synthetic dilators containing magnesium sulfate (Lamicel) inserted into endocervix without rupturing membranes. Left in place for 6-12 hours, can be reinserted if necessary. Discomfort at insertion and expansion, higher incidence of postpartum maternal and newborn infections. Document, assess for urinary retention, ROM, uterine tenderness or pain, contractions, vaginal bleeding, infection, fetal distress
Amniotic membrane stripping or sweeping
Inducing labor through release of prostaglandins and oxytocin. Separation of membrane from wall of cervix and lower uterine segment by inserting finger into internal cervical os and rotating 360 degrees. Best with primigravida at term with unripe cervix, vertex well applied to cervix. Uncomfortable, risk of infection, ROM, bleeding, precipitous labor and birth. Routine not recommended, may be offered after 39 weeks.
Physical Methods of Dilation
Sexual intercourse (prostaglandins in semen, stimulation of contractions with orgasm), nipple stimulation (release of oxytocin), walking (gravity on cervix, oxytocin release). Nipple stimulation (enhance and induce). Ambulation effective to augment labor
Artificial rupture of membranes (AROM) used to induce labor when condition of cervix is ripe or to augment labor if progress begins too slow. Labor begins within 12 hours of rupture. Decrease duration of labor by up to 2 hours, even without oxytocin.
If does not stimulate labor, resulting prolonged rupture may lead to intraamniotic infection. Variable FHR decels can occur as result of cord compression associated with umbilical cord prolapse or decreased amniotic fluid. Committed to labor once amniotomy performed (often used in combination with oxytocin).
Explain what will be done, assess FHR and pattern before to get baseline, underpads under buttocks, position on padded bedpan, fracture pan, rolled up towels (to elevate hips), assist HCP with procedure by providing sterile gloves and lubricant to examination, unwrap sterile package containing Amnihook or Allis clam and pass to HCP, reassess FHR and pattern, assess color, consistency, odor of fluid, assess temp every 2 hrs (38 or higher bad), evaluate for s/s of infection. Document: FHR and pattern before and after, time of rupture, color, odor, consistency of fluid (look for meconium and blood), maternal status (tolerant of procedure?)
Painless for mother and fetus, some discomfort as instrument inserted through vagina and cervix. Presenting part of fetus should be well applied to cervix BEFORE procedure to prevent cord prolapse. Should be free of infection of genital tract, HIV negative. FHR: transient tachycardia common, bradycardia, variable decels not, may indicate cord prolapse or compression.
Amniotomy signs of infection
Maternal chills, uterine tenderness on palpation, foul-smelling vaginal drainage, fetal tachycardia
Hormone normally produced by posterior pituitary. Stimulates uterine contractions and aids in milk let-down. Synthetic oxytocin (Pitocin) may be used to induce or augment labor. Most common drug associated with adverse events during childbirth (mainly dosage errors). High-alert list. Goal: produce contractions of normal intensity, duration, frequency while using lowest dose of med possible
Maternal hazards of Pitocin
Placental abruption, uterine rupture, unnecessary cesarean birth because of abnormal FHR and patterns, postpartum hemorrhage and infection
Fetal hazards of Pitocin
Placental perfusion diminished by contractions too frequent or prolonged: hypoxemia and acidemia, eventually leads to late decels and minimal or absent baseline variability.
Low-dose physiologic protocols for administering oxytocin
Starting dose of 1 milliunit/min, increase by 1-2 milliunits/min no more frequently than every 30-60 mins. Uterus responds within 3-5 minutes, half life is 10-12 minutes, approx 40 mins of pitocin needed to reach steady state. Result in decreased risk for oxytocin-induced tachysystole and unnecessary c-section
High-dose protocols for administering oxytocin
Initial dose of oxytocin is larger and increased more rapidly, found to result in shorter labors, less forceps-assisted births, fewer c-sections because of dystocia, less chorioamnionitis, less neonatal sepsis. But it is associated with more uterine tachysystole, more c-sections related to fetal stress. Some administer in 8 to 10 minute pulsed infusions rather than continuous infusion. More like endogenous secretion of oxytocin.
More than 5 contractions in 10 minutes, averaged over a 30 minute window. OR series of single contractions lasting longer than 2 minutes. OR contractions of normal duration occurring within 1 minute of each other. Occurs both in spontaneous and stimulated labor. Interventions implemented immediately, HCP informed of interventions, response of mother and fetus.
Tachysystole Interventions: Category I FHR Tracing
Side-lying position, administer IV fluid bolus with 500 mL of LR's solution, if not returned to normal after 10 minutes: decrease oxytocin dose by at least half. Not returned after another ten minutes: discontinue infusion until fewer than five contractions in ten minutes.
Tachysystole Interventions: Category II (abnormal) FHR Tracing
Discontinue oxytocin infusion immediately, reposition or maintain woman in side-lying position, consider giving oxygen at 10 L/min if previous interventions do not resolve FHR tracing, still no response: give .25 mg terbutaline subcutaneously, notify HCP of actions taken and response.
Resumption of Oxytocin After Resolution of Tachysystole
D/C for less than 20-30 mins, resume at no more than half the rate that caused tachysystole. If more than 30-40 mins, resume at initial starting dose
Augmentation of Labor
Stimulation of uterine contractions after labor has started spontaneously but progress is unsatisfactory. Usually for hypotonic uterine dysfunction, resulting in slowing of labor process (protracted active phase). Oxytocin infusion and amniotomy. Noninvasive: emptying bladder, ambulation and position changes, relaxation measures, nourishment and hydration, hydrotherapy should be attempted first.
Active management of labor
Augmentation of labor to establish efficient labor and aggressive use of oxytocin so women gives birth within 12 hours of admission to labor unit. Intervening early (nulliparous not progressing at 1 cm/hr), use of higher oxytocin doses at frequent incremental intervals (starting at 6 with increase by 6 every 15 minutes). Strict criteria to make sure in active labor, amniotomy within 1 hr of admission if spontaneous rupture does not occur, continuous presence of nurse who provides 1-1 care. ONLY on nulliparous who began laboring spontaneously
Operative vaginal birth
Forceps or vacuum extractor, use is declining.
Forceps assisted birth
An instrument with two curved blades is used to assist in the birth of the fetal head. Pelvic curve to blades conforming to curve of pelvic axis. Locks present forceps from compressing fetal skull. Types of forceps-assisted births: outer, low, midpelvis.
Maternal indications for forceps-assisted birth
Prolonged second stage of labor, need to shorten second stage of labor for maternal reasons (exhaustion, cardiopulmonary, cerebrovascular disease).
Fetal indications for forceps-assisted birth
Abnormal FHR tracing or certain abnormal presentations, arrest of rotation, or extraction of head in a breech presentation
Conditions of forceps birth in order to be successful
Cervix must be fully dilated, bladder should be empty, presenting part engaged (vertex desired), membranes must be ruptured, size of maternal pelvis
Nursing considerations: forceps
Forceps fit around head like two tablespoons around an egg, blades in front of baby's ears. Mother: after birth assessed for vaginal or cervical lacerations, urinary retention, hematoma formation in pelvic soft tissues. Infant: bruising, abrasions, facial palsy from pressure on facial nerve, subdural hematoma
Outlet Forceps and vacuum assisted births
Fetal scalp is visible on perineum without manually separating labia
Low forceps and vacuum assisted births
Fetal head is at least at +2 station
Midpelvis forceps and vacuum assisted births
Fetal head engaged, no higher than 0 station, but above +2 station
Attachment of vacuum cup to fetal head, using negative pressure to assist in birth of the head. Generally not used before 34 weeks gestation. Completely dilated cervix, ruptured membranes, engaged head, vertex presentation, no suspicion of CPD. Easy to place and less anesthesia then forceps. Nurse may need to connect suction tubing attached to cup to wall suction or separate hand pump and generates pressure requested by physician. If not successful, forceps or c-section usually follows.
Risks to newborn with vacuum-assisted birth/maternal risks
Cephalhematoma, scalp lacerations, subdural hematoma. Maternal: perineal, vaginal, cervical lacerations and soft tissue hematomas
Nursing Considerations for vacuum-assisted birth
Support and educate. FHR should be assessed frequently during procedure. Documentation of procedure often nursing responsibility. After birth: observed for signs of trauma and infection at application site and cerebral irritation (poor sucking, listlessness). Risk for hyperbilirubinemia, jaundice as bruising resolves. Caput succedaneum: goes away 3-5 days
Birth of a fetus through a transabdominal incision of the uterus. Purpose is to preserve life or health of mother and fetus. Incisions made in lower uterine segment rather than muscular body of uterus, promoting effective healing.
Indications of c-section (maternal)
Maternal: specific cardiac disease, specific respiratory disease, conditions associated with increased intracranial pressure, mechanical obstruction of lower uterine segment, mechanical vulvar obstruction, hx of previous c-section.
Indications of c-section (Fetal)
Abnormal FHR or pattern, malpresentation, active maternal herpes lesions, maternal HIV, congenital anomalies
Indications of c-section (maternal-fetal)
Dysfunctional labor, placental abruption, placenta previa, elect c-section
Elective Cesarean birth
Without medical or obstetric indication. Convenience, anxiety of pain, fright, previous bad experiences with vaginal births. Potential risks: higher rate of endometritis, blood transfusion, venous thrombosis, longer hospital stay and recovery time, increased risk of respiratory problems for baby, greater complications in subsequent pregnancies (uterine rupture, placental implantation problems). Not performed before 39 weeks
Scheduled Cesarean Birth
Labor and vaginal birth contraindicated (complete placenta previa, active genital herpes, positive HIV with high viral load), birth necessary but labor not inducible (hypertensive states), course of action chosen by HCP and woman
Unplanned cesarean birth
May be traumatic and psychologically harmful. Fear, discouraged, little time for explanation of procedures and operation. Fatigue.
Forced Cesarean birth
Woman's refusal to undergo cesarean indicated for fetal reasons described as maternal-fetal conflict. May get court order for surgery. Every effort made to avoid this legal step
Skin incision options for Cesarean
Vertical (extending from umbilicus to mons pubis, or transverse (Pfannenstiel) in lower abdomen (performed most often). Determined by urgency of surgery, presence of prior skin incisions.
Low transverse incision and vertical incision (low or classic). Ideally: vertical incision contained within lower uterine segment, but extension into contractile portion of uterus can occur.
Indications for vertical uterine incision
Underdeveloped lower uterine segment, transverse lie or preterm breech presentation, certain fetal anomalies, anterior placental previa. Vaginal birth after classic uterine incision contraindicated because of high incidence of uterine rupture in subsequent pregnancies.
Low transverse incision of uterus
Does not compromise upper uterine segment, easier to perform and repair, associated with less blood loss. Preferred. Option of trial of labor and VBAC in subsequent pregnancies.
Complications and risks of cesarean (Maternal)
Aspiration, hemorrhage, atelectasis, endometritis, abdominal wound dehiscence or infection, urinary tract infection, injuries to bladder or bowel, complications of anesthesia. Cost of surgery higher.
Fetal complications and risks of cesarean
May be born premature if gestational age not accurately determined, fetal asphyxia if uterus and placenta poorly perfused as result of maternal hypotension from anesthesia or positioning. Fetal injuries (scalpel lacerations), resuscitation efforts and respiratory problems more likely.
Anesthesia for Cesarean
Spinal, epidural, general. Epidural popular (mother wants to be awake). Time, mother's medical hx. General used if emergency and life of mother of infant in stake.
Preoperative care for cesarean
Family centered, kept informed. NPO at least 8 hours before surgery. Informed consent. Blood tests before planned cesarean or on admission (CBC, blood type, Rh status). Maternal VS, FHR and pattern until operation begins. IV fluids to maintain hydration, open line for administration of blood or meds as needed. Make sure consent form signed, insert foley, preop meds (prevent aspiration pneumonia, prophylactic antibiotics to prevent postop infection). TED hose, SCDs prevent blood clots. Partner stays with mother.
Intraoperative care for cesarean
Partner in OR. Positioning of woman on table, uterus should be displaced laterally to prevent compression of inferior vena cava (deceased placental perfusion). Wedge under hip or tilting table. Legs strapped to table. Foley. Awake: let her know what is happening, provide support. Nurse present to provide infant care, pediatric team skilled in neonatal resuscitation may be there. Detect normal and abnormal fetal responses. Should be placed skin-to-skin if possible right after birth. Compromised: transported after initial stabilization for observation and interventions. Never give up any information to family without checking with mother first (legal).
Immediate Postop care for cesarean
PACU. Focus: recovery from effects of anesthesia, postop and postbirth status, degree of pain. Patent airway maintained, positioned to prevent possible aspiration. Vitals every 15 mins for 1-2 hours, or until stable. Condition of incisional dressing, fundus, amount of lochia assessed, IV intake and urine output through foley. Oxytocin added to first liter of IV to maintain fundus contracted, reducing blood loss. Turned, cough, deep breath, leg exercises. Meds for pain before it becomes severe. Breastfeeding and alone time needed asap. PACU discharge: alert, oriented, stable, effects of anesthesia worn off
Pain postpartum care
Pain from incisional site and gas. 24 hours after surgery: epidural opioids, PCA, IV or IM injections. Opioids used: antiemetic often administered. Palpation of fundus, massage performed after analgesic given to decrease pain. After first 24: oral analgesics. Position changes, splinting of incision with pillows, relaxation and breathing techniques. NPO until BS sometimes, then advanced to full liquids, passing flatus: reg diet. IV until can tolerate oral fluids. Adequate rest and pain relief big.
Daily Postpartum care
Perineal care, breast care, routine hygienic care. Shower after original incisional dressing removed, foley removed first postpartum day. Out of bed and ambulating, TED and SCDs can be removed after begins ambulating. Should ask for help getting out of bed (dizziness). VS, incision, fundus, lochia, breath sounds, BS, circulatory status of lower extremities, urinary and bowel elimination patterns, maternal emotional status, progress of attachment to baby. Assistance/teaching infant care to mother.
Discharge after Cesarean
Usually third postop day. Up to 96 hours after birth. Discharge teaching: nutrition, measures to relieve pain and discomfort, exercise and specific activity restrictions, time management about rest and sleep, hygiene, breast, incision care, timing for resumption of sexual activity and contraception, signs of complications, infant care.
Signs of Postop complications following cesarean (discharge)
Temp exceeding 38 or 100.4; painful urination, urgency, cloudy urine; lochia heavier than menstrual period, clots, odor; redness, swelling, bruising, foul-smelling discharge or bleeding, wound separation of incision; severe, increasing abdominal pain
Trial of Labor (TOL)
Observance of a woman and fetus for a reasonable period of time (4-6 hrs) of spontaneous active labor to assess safety of vaginal birth for mother and infant. Initiated: pelvis questionable size or shape, fetus abnormal presentation or position, or vaginal birth after previous c-section (low transverse may be candidate). During: monitored for active labor, adequate contractions, engagement and descent, dilation of cervix.
TOL assessing for possible complications
Maternal VS, FHR and pattern. Complications develop: initiate appropriate actions, notify HCP, evaluate and document responses to interventions.
Criteria for vaginal birth after cesarean
One or two previous low-transverse cesarean births, clinically adequate pelvis, no other uterine scars or hx of previous rupture, physicians available throughout active labor to preform emergency c-section if needed
Vaginal Birth After Cesarean (VBAC)
Successful VBAC: less hemorrhage, fewer infections, shorter recovery period than those who have repeat cesarean. Risk associated with VBAC: uterine rupture. Other risks: operative injury, blood transfusion, hysterectomy, endometritis, maternal death.
Factors that indicate less likely to have successful VBAC
Recurrent indication (labor dystocia) for initial cesarean birth, increased maternal age, non-caucasian, gestation over 40, maternal obesity, preeclampsia, short interpregnancy interval, increased neonatal birthweight
Meconium-stained amniotic fluid
Indicates fetus has passed meconium (first stool) before birth. Fluid green. Thin or thick depending on amount of meconium present. Three possible reasons: normal and occurs with maturity or breech presentation, result of hypoxic-induced peristalsis and sphincter relaxation, sequel to umbilical cord compression-induced vagal stimulation in mature fetuses.
Meconium aspiration syndrome (MAS)
Major risk associated with meconium-stained fluid. Severe form of aspiration pneumonia, occurs most often in term or postterm infants. Long standing intrauterine process rather than from aspiration immediately after birth as respirations initiated. Team skilled in neonatal resuscitation vital. Management based on assessment of condition at birth.
Immediate management of newborn with meconium-stained amniotic fluid (before birth)
Assess amniotic fluid fro presence of meconium after ROM. Gather equipment and supplies that might be necessary for resuscitation. At least one person capable of endotracheal intubation on baby present at birth.
Immediate management of newborn with meconium-stained amniotic fluid (after birth)
Immediately after birth: assess respiratory efforts, HR, muscle tone. Suction only baby's mouth and nose using bulb syringe or suction catheter if baby has strong respiratory efforts, good muscle tone, HR above 100 bpm. Suction trachea w/ endotracheal tube connected to meconium aspiration device and suction source to remove meconium present if: depressed respirations, decreased muscle tone, HR less than 100 bpm
Uncommon obstetric emergency that increases risk for fetal and maternal morbidity and mortality during vaginal birth attempt. Head born but anterior shoulder cannot pass under pubic arch. Fetopelvic disproportion related to macrosomic infants (above 4000 g) may be a cause, half do occur in smaller fetuses though. Maternal diabetes, history of shoulder dystocia. May have no risk factors. Cannot be predicted or prevented. Major maternal complication: postpartum hemorrhage, rectal injuries
Retraction of fetal head against perineum immediately after emergency is an early warning sign that birth of shoulders may be difficult
Shoulder dystocia and fetal injuries
Usually caused by asphyxia related to delay in completing birth or trauma from maneuvers used to accomplish birth. Trauma: brachial plexus and phrenic nerve injuries and fracture of humerus or clavicle. Most serious is brachial plexus injury
Brachial plexus injury
Erb palsy. Most serious complication. May result from intrauterine forces during second stage of labor rather than from maneuvers to accomplish birth. If recognized early, tx properly most heal completely. Permanent neurologic injury rare.
Woman's legs flexed apart with knees on abdomen. Causes sacrum to straighten, symphysis pubis to rotate toward mother's head, angle of pelvic inclination decreased, frees shoulder. Preferred method when epidural anesthesia received
Hands-and-knees position, requires woman to be mobile (not regional anesthesia).
Fundal pressure for shoulder dystocia
AVOID. Associated with neurologic complications
Newborn: look for fx of clavicle, humerus, brachial plexus injuries, asphyxia.
Maternal: detection of hemorrhage, trauma to vagina, perineum, rectum
Prolapsed Umbilical Cord
Cord lies below presenting part of fetus. May be occult (hidden) at any time during labor. Most common to see frank (visible) prolapse directly after ROM, gravity pushes cord in front of presenting part. Factors: long cord (100 cm or longer), malpresentation, unengaged presenting part, does not fit snugly. May prolapse during amniotomy if presenting part too high. Small fetus not fitting snugly
Management of prolapsed cord
Prompt recognition, fetal hypoxia from prolonged cord compression (more than 5 minutes) resulting in CNS damage or death of fetus. Examiner can stick fingers up and hold presenting part off cord. Modified Sims', Trendelenburg, knee-chest (gravity keeps pressure off presenting part). Cesarean, forceps or vacuum (if vertex). Abnormal FHR/pattern, inadequate uterine relaxation, bleeding can occur as result.
Signs of prolapsed umbilical cord
Variable or prolonged decels during uterine contractions, woman reports feeling cord after membrane rupture, cord seen or felt in or protruding from vagina
Interventions for prolapsed umbilical cord
Call for assistance, someone notify HCP immediately, don't leave her alone, glove examining hand quickly, insert 2 fingers in vagina to cervix, one finger on either side of cord or both fingers on one side, exert upward pressure against presenting part to relieve compression of cord. Do not move hand. Rolled towel under hip. Extreme trendelenburg or modified sims, or kneechest. Cord protruding from vagina: wrap loosely in sterile towel saturated with warm sterile normal saline solution. Do not attempt to replace cord into cervix. Oxygen nonbreather mask, 8-10 L until birth. IV fluids, FHR continuously monitored (internal fetal scalp electrode)
Rupture of the Uterus
Complete nonsurgical disruption of all uterine layers, rare but serious obstetric injury. Major risk factor: scarred uterus from previous cesarean or uterine surgery. During TOL or VBAC usually. Most often with classic incision. Multiple prior cesarean births, no previous vaginal births, induced or augmented labor, term gestation, multifetal gestation, fetal macrosomia, post-cesarean birth infection, short interpregnancy interval
Incomplete uterine rupture, separation of prior scar. May go unnoticed. Does not result in hemorrhage.
Signs and symptoms of rupture of uterus
Most common: abnormal FHR tracing, esp variable or prolonged decels or bradycardia. Loss of fetal station. Constant abdominal pain, uterine tenderness, change in uterine shape, cessation of contractions. May have hypovolemic shock caused by hemorrhage (hypotension, tachypnea, pallor, cool, clammy skin). Placenta separates: FHR absent, fetal parts may be palpable through abdomen
Prevention or rupture of uterus
Prevention best. Classic incision: not advised to labor or attempt vaginal birth. Risk: assessed closely during labor. Induced: monitored for tachysystole, can precipitate uterine rupture. If occurs: oxytocin D/C or decreased, tocolytic med given to decrease uterine contractions. After: assessed for excessive bleeding, esp if fundus firm and signs of hemorrhagic shock present.
Management of rupture of uterus
Depends on severity. Small managed with laparotomy and birth of infant, repair of laceration, blood transfusions. Hysterectomy if rupture large and difficult to close, or hemodynamically unstable. Nurse: IV, transfuse blood products, oxygen, prep for surgery. Fetal mortality rate high: 50-70%, maternal: substantial.
Amniotic Fluid Embolus (AFE) OR anaphylactoid syndrome of pregnancy
Rare, characterized by sudden, acute onset of hypoxia, hypotension, cardiovascular collapse, coagulopathy. During labor, during birth, 30 minutes after birth. Foreign substance (present in amniotic fluid) enters circulation, resulting in DIC, hypotension, hypoxia. Fetal debris may play role. Mortality: 61% or higher. Neonatal outcomes poor, if before birth: survival 80%, only half without neurologic impairment.
Maternal risk factor for AFE
Advanced age, minority race, placenta previa, preeclampsia, forceps-assisted or cesarean birth. Rapid labor (hypertonic contractions), meconium staining.
Management of AFE
CPR often necessary. Maternal cardiac arrest: perimortem cesarean should be accomplished within 5 minutes. Nurse's immediate responsibility is assist with resuscitation. Mother survives: blood replacement, clotting factors, hydration, BP, mechanical vent, hemodynamic monitoring.
Signs of AFE
Respiratory distress: restlessness, dyspnea, cyanosis, pulmonary edema, respiratory arrest.
Circulatory collapse: hypotension, tachycardia, shock, cardiac arrest
Hemorrhage: coagulation failure (bleeding from incisions, venipuncture sites, trauma), petechiae, ecchymosis, purpura
AFE Immediate Interventions
Oxygenate nonrebreather mask (8-10 L/min) or resuscitation bag with 100% oxygen, prepare for intubation and mechanical ventilation, CPR, tilt at 30 degrees to side to displace uterus. CO and fluid losses: woman on side, IV fluids, blood products, catheter to measure output. Correct coagulation failure, monitor fetal and maternal status, prepare for emergency birth when condition stable, emotional support.
Sets found in the same folder
Women's and Children's Exam 3 Spr 2021
Ch 17 - Labor and Birth Complications evolve nclex
Chapter 12 High Risk Perinatal Care: Gestational C…
Sets with similar terms
Labor and Birth Complications
Labor and Birth Complications
Labor and Birth Complications
complications during labor and birth ch 8
Other sets by this creator
Patho Chapter 3
Basic concepts of medications
NCLEX Important Laboratory Values
Other Quizlet sets
Mid term review part 2
Test 1: Book Study Guide
Mammology Exam 1
Variable decelerations that have a slow return to baseline, an increased baseline (tachycardia) or absence of variability, regardless of depth of fall may indicate...
what clotting factors are increased during pregnancy?
What is the intention of fetal monitoring: what are we trying to prevent
What are the indications for a VBAC?