Chapter 21: Nursing Management of Labor and Birth at Risk

Uterine rupture

A catastrophic tearing of the uterus at the site of a previous scar into the abdominal cavity. Its onset is often marked only by sudden fetal bradycardia, and treatment requires rapid surgery for good outcomes. From the time of diagnosis to delivery, only 10 to 30 minutes are available before clinically significant fetal morbidity occurs. Fetal morbidity occurs secondary to catastrophic hemorrhage, fetal anoxia, or both.

Fetal fibronectin

A glycoprotein produced by the chorion, is found at the junction of the chorion and decidua (fetal membranes and uterus). It acts as biologic glue, attaching the fetal sac to the uterine lining. It normally is present in cervicovaginal secretions up to 22 weeks of pregnancy and again at the end of the last trimester (1 to 3 weeks before labor). It usually cannot be detected between 24 and 34 weeks of pregnancy (5½ to 8½ months) unless there has been a disruption between the chorion and deciduas. It is present in cervicovaginal fluid prior to delivery, regardless of gestational age. The test is a useful marker for impending membrane rupture within 7 to 14 days if the level increases to greater than 0.05 mcg/mL. The accuracy of fetal fibronectin is decreased in the presence of lubricants, blood, recent intercourse, or cervical manipulation within the previous 24 hours. Conversely, a negative fetal fibronectin test is a strong predictor that preterm labor in the next 2 weeks is unlikely A sterile applicator is used to collect a cervicovaginal sample during an examination by speculum. The result is either positive (fetal fibronectin is present) or negative (fetal fibronectin is not present). Interpretation of fetal fibronectin results must always be viewed in conjunction with the clinical findings; it is not used as a lone indicator for predicting preterm labor. The primary importance of cervicovaginal fetal fibronectin lies in the high negative predictive values of the test for reducing preterm birth risk.

Oxytocin

A potent endogenous uterotonic agent used for both artificial induction and augmentation of labor. It is produced naturally by the posterior pituitary gland and stimulates contractions of the uterus. For women with low Bishop scores, cervical ripening is typically initiated before oxytocin is used. Once the cervix is ripe, oxytocin is the most popular pharmacologic agent used for inducing or augmenting labor. The most common adverse effect of oxytocin is uterine hyperstimulation, leading to fetal compromise and impaired oxygenation The response of the uterus to the drug is closely monitored throughout labor so that the oxytocin infusion can be titrated appropriately. In addition, oxytocin has an antidiuretic effect, resulting in decreased urine flow that may lead to water intoxication. Symptoms to watch for include headache and vomiting. Oxytocin is administered via an intravenous infusion pump piggybacked into the main intravenous line at the port most proximal to the insertion site. Typically, 10 units of oxytocin is added to 1 L of isotonic solution. The dose is titrated according to protocol to achieve stable contractions every 2 to 3 minutes lasting 40 to 60 seconds. The uterus should relax between contractions. If the resting uterine tone remains above 20 mm Hg, uteroplacental insufficiency and fetal hypoxia can result Oxytocin has many advantages: it is potent and easy to titrate, it has a short half-life (1 to 5 minutes), and it is generally well tolerated. Induction using oxytocin has side effects (water intoxication, hypotension, and uterine hypertonicity), but because the drug does not cross the placental barrier, no direct fetal problems have been observed

external cephalic version

A procedure in which the fetus is rotated from the breech to the cephalic presentation by manipulation through the mother's abdominal wall at or near term. This maneuver may be offered to women between 36 and 38 weeks' gestation. It is performed only in a hospital setting under direct ultrasound guidance and continuous fetal monitoring. Women with a breech presentation today are often advised to have a surgical birth with no attempt to rotate the fetal position

Cervical ripening

A process by which the cervix softens via the breakdown of collagen fibrils. It is the first step in the process of cervical effacement and dilation so that, on average, the cervix is approximately 50% effaced and 2 cm dilated at the onset of labor, although wide differences do exist Cervical ripeness is an important variable when labor induction is being considered. A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm. Cervical ripening usually begins prior to the onset of labor contractions and is necessary for cervical dilation and the passage of the fetus. The Bishop score helps identify women who would be most likely to achieve a successful induction Medical induction of labor has two components: cervical ripening and induction of contractions. When induction of labor is indicated, cervical readiness for labor is evaluated by pelvic examination and determination of a Bishop score is documented. Nonpharmacologic methods for cervical ripening are less frequently used today, but nurses need to be aware of them and question clients about their use. Methods may include herbal agents such as evening primrose oil, black haw, black and blue cohosh, and red raspberry leaves. Another nonpharmacologic method suggested for labor induction is sexual intercourse along with breast stimulation. This promotes the release of oxytocin, which stimulates uterine contractions. In addition, human semen is a biologic source of prostaglandins used for cervical ripening Mechanical methods are used to open the cervix and stimulate the progression of labor. All share a similar mechanism of action: application of local pressure stimulates the release of prostaglandins to ripen the cervix. The risks associated with these methods include infection, bleeding, membrane rupture, and placental disruption Hygroscopic dilators absorb endocervical and local tissue fluids; as they enlarge, they expand the endocervix and provide controlled mechanical pressure. The products available include natural osmotic dilators (laminaria, a type of dried seaweed) and synthetic dilators containing magnesium sulfate (Lamicel, Dilapan) Placement of dilators also requires additional training and may be associated with rupture of membranes, vaginal bleeding, and client discomfort or pain Surgical methods used to ripen the cervix and induce labor include stripping of the membranes and performing an amniotomy. Stripping of the membranes is accomplished by inserting a finger through the internal cervical os and moving it in a circular direction. This motion causes the membranes to detach. An amniotomy involves inserting a cervical hook (Amniohook) through the cervical os to deliberately rupture the membranes. This promotes pressure of the presenting part on the cervix and stimulates an increase in the activity of prostaglandins locally. Risks associated with these procedures include umbilical cord prolapse or compression, maternal or neonatal infection, FHR deceleration, bleeding, and client discomfort The use of prostaglandins to attain cervical ripening has been found to be highly effective in producing cervical changes independent of uterine contractions Prostaglandin analogs commonly used for cervical ripening include dinoprostone gel (Prepidil), dinoprostone inserts (Cervidil), and misoprostol (Cytotec). A major adverse effect of the obstetric use of Cytotec is hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingooophorectomy), or amniotic fluid embolism (AFE) Furthermore, it is contraindicated for women with prior uterine scars and therefore should not be used for cervical ripening in women attempting a vaginal birth after cesarean (VBAC).

Umbilical cord prolapse

A rare obstetrical emergency that occurs when the cord precedes the fetus out. An umbilical cord prolapse is the protrusion of the umbilical cord alongside (occult) or ahead of the presenting part of the fetus Prolapse usually leads to total or partial occlusion of the cord. Since this is the fetus's only lifeline, fetal perfusion deteriorates rapidly. Complete occlusion renders the fetus helpless and oxygen deprived. The fetus will die if the cord compression is not relieved.

Amniotic fluid embolism

Amniotic fluid containing particles of debris (e.g., hair, skin, vernix, or meconium) enters the maternal circulation and obstructs the pulmonary vessels, causing respiratory distress and circulatory collapse It is a rare and often fatal event characterized by the sudden onset of hypotension, hypoxia, and coagulopathy. An embolus occurs when the barrier between the maternal circulation and the amniotic fluid is broken and amniotic fluid enters the maternal venous system via the endocervical veins, the placental site (if the placenta is separated), or a site of uterine trauma.

Nursing assessment of cesarean birth

Any condition that prevents the safe passage of the fetus through the birth canal or that seriously compromises maternal or fetal well-being may be an indication for a cesarean birth. Examples of specific indications include active genital herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental abnormality (placenta previa or abruptio placentae), previous classic uterine incision or scar, gestational hypertension, diabetes, positive human immunodeficiency virus (HIV) status, and dystocia. Fetal indications include malpresentation (nonvertex presentation), congenital anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects), and fetal distress

Nursing assessment of preterm labor

Ask the woman about any complaints, being alert for the subtle symptoms of preterm labor, which may include: Change or increase in vaginal discharge with mucus, water, or blood in it Pelvic pressure (pushing-down sensation) Low, dull backache Menstrual-like cramps Urinary tract infection symptoms Feeling of pelvic pressure or fullness Gastrointestinal upset: nausea, vomiting, and diarrhea General sense of discomfort or unease Heaviness or aching in the thighs Uterine contractions, with or without pain More than six contractions per hour Intestinal cramping, with or without diarrhea Assess the pattern of the contractions: the contractions must be persistent, such that four contractions occur every 20 minutes or eight contractions occur in 1 hour. Evaluate cervical dilation and effacement: cervical effacement is 80% or greater and cervical dilation is greater than 1 cm Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count to detect infection, which may be a contributing factor to preterm labor; urinalysis to detect bacteria and nitrites, which are indicative of a urinary tract infection; and an amniotic fluid analysis to determine fetal lung maturity and the presence of subclinical chorioamnionitis. Other tests that may be used for preterm labor prediction include fetal fibronectin testing and cervical length evaluation by transvaginal ultrasound.

Nursing management of cesarean birth

Assist with obtaining diagnostic tests as ordered. These tests are usually ordered to ensure the well-being of both parties and may include a complete blood count; urinalysis to rule out infection; blood type and cross-match so that blood is available for transfusion if needed; an ultrasound to determine fetal position and placental location; and an amniocentesis to determine fetal lung maturity if needed. Encourage the woman to report any pain. Ask the woman about the time she last had anything to eat or drink. Document the time and what was consumed. Throughout the preparations, assess maternal and fetal status frequently. Demonstrate the use of the incentive spirometer and deep-breathing and leg exercises. Instruct the woman on how to splint her incision. Complete the preoperative procedures, which may include: Preparing the surgical site as ordered Starting an intravenous infusion for fluid replacement therapy as ordered Inserting an indwelling (Foley) catheter and informing the client about how long it will remain in place (usually 24 hours) Administering any preoperative medications as ordered; documenting the time administered and the client's reaction Assess vital signs and lochia flow every 15 minutes for the first hour, then every 30 minutes for the next hour, and then every 4 hours if stable. Assist with perineal care and instruct the client in the same. Inspect the abdominal dressing and document description, including any evidence of drainage. Assess uterine tone to determine fundal firmness. Check the patency of the intravenous line, making sure the infusion is flowing at the correct rate. Inspect the infusion site frequently for redness. Assess the woman's level of consciousness if sedative drugs were administered. Institute safety precautions until the woman is fully alert and responsive. If a regional anesthetic was used, monitor for the return of sensation to the legs. Assess for evidence of abdominal distention and auscultate bowel sounds. Assist with early ambulation to prevent respiratory and cardiovascular problems and to promote peristalsis. Monitor intake and output at least every 4 hours initially and then every 8 hours as indicated. Encourage the woman to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. Enhance comfort and general well-being. Administer analgesics as ordered and provide comfort measures, such as splinting the incision and pillows for positioning. Assist the client to move in bed and turn side to side to improve circulation. Also encourage the woman to ambulate to promote venous return from the extremities. Prevent/minimize postoperative complications.

Nursing assessment of umbilical cord prolapse

Carefully assess each client to help predict her risk status. Be aware that cord prolapse is more common in pregnancies involving malpresentation, growth restriction, prematurity, ruptured membranes with a fetus at a high station, hydramnios, grandmultiparity, and multiple gestation Continuously assess the client and fetus to detect changes and to evaluate the effectiveness of any interventions performed.

Risk factors for dystocia

Epidural analgesia excessive analgesia multiple pregnancy hydramnios maternal exhaustion ineffective maternal pushing technique occiput posterior position longer first stage of labor nulliparity short maternal stature (less than 5 ft tall) fetal birth weight (more than 8.8 lb) shoulder dystocia abnormal fetal presentation or position (breech) fetal anomalies (hydrocephalus) maternal age older than 34 years high caffeine intake overweight gestational age more than 41 weeks chorioamnionitis ineffective uterine contractions high fetal station at complete cervical dilation.

Intrauterine fetal demise

Fetal death that occurs after 20 weeks' gestation but before birth. Can be due to an extensive range of risk factors and possible causes, such as postterm pregnancy, renal disease, substance abuse, infection, hypertension, advanced maternal age, multiple gestation, Rh disease, uterine rupture, diabetes, congenital anomalies, obesity, smoking, cord accident, abruption, blunt trauma, premature rupture of membranes, or hemorrhage—or it may go unexplained A fetal death can occur at any gestational age, and typically there is little or no warning other than reduced fetal movement. Once IUFD is confirmed, most women choose to immediately undergo induction of labor. Approximately 90% of women will go into spontaneous labor within 2 weeks of fetal death In general, the grief accompanying the loss of a fetus proceeds in the following order: Accepting the reality of the loss Getting over suffering from the loss Adapting to the new environment without the deceased Emotionally relocating the deceased and getting on with life

Nursing management of labor induction

If not already done, prepare the oxytocin infusion by diluting 10 units of oxytocin in 1,000 mL of lactated Ringer solution or ordered isotonic solution. Use an infusion pump on a secondary line connected to the primary infusion. Start the oxytocin infusion in mU/min or milliliters per hour as ordered. During induction or augmentation, monitoring of the maternal and fetal status is essential. Apply an external electronic fetal monitor or assist with placement of an internal device. Obtain the mother's vital signs and the FHR every 15 minutes during the first stage. Evaluate the contractions (frequency, duration, and intensity) and resting tone, and adjust the oxytocin infusion rate accordingly. Monitor the FHR, including baseline rate, baseline variability, and decelerations, to determine whether the oxytocin rate needs adjustment. Discontinue the oxytocin and notify the birth attendant if uterine hyperstimulation or a category II or III FHR pattern occurs. Perform or assist with periodic vaginal examinations to determine cervical dilation and fetal descent: cervical dilation of 1 cm/hr typically indicates satisfactory progress. Continue to monitor the FHR continuously and document it every 15 minutes during the active phase of labor and every 5 minutes during the second stage. Assist with pushing efforts during the second stage. Measure and record intake and output to prevent excess fluid volume. Encourage the client to empty her bladder every 2 hours to prevent soft tissue obstruction. Ask her frequently to rate her pain and provide pain management as needed. Offer position changes and other nonpharmacologic measures. Note her reaction to any medication given, and document its effect. Monitor her need for comfort measures as contractions increase.

Nursing management of amniotic fluid embolism

Institute supportive measures: oxygenation (resuscitation and 100% oxygen), circulation (intravenous fluids, inotropic agents to maintain cardiac output and blood pressure), control of hemorrhage and coagulopathy (oxytocic agents to control uterine atony and bleeding), seizure precautions, and administration of steroids to control the inflammatory response. Monitor vital signs, pulse oximetry, skin color, and temperature and observe for clinical signs of coagulopathy (vaginal bleeding, bleeding from intravenous site, bleeding from gums) Adequate oxygenation is necessary, with endotracheal intubation and mechanical ventilation for most women. Vasopressors are used to maintain hemodynamic stability. Management of DIC may involve replacement with packed red blood cells or fresh-frozen plasma as necessary. Oxytocin infusions and prostaglandin analogs can be used to address uterine atony.

Labor induction

Involves the stimulation of uterine contractions by medical or surgical means before the onset of spontaneous labor. Labor induction also involves intravenous therapy, bed rest, continuous electronic fetal monitoring, significant discomfort from stimulating uterine contractions, epidural analgesia/anesthesia, and a prolonged stay on the labor and birth unit Labor augmentation (stimulating the uterus, typically with oxytocin) enhances ineffective contractions after labor has begun. Continuous electronic FHR monitoring is necessary. Labor induction should be performed only for a clear medical indication Women being induced should not be left unattended Labor induction should only be performed after CPD has been ruled out Labor induction should be applied to women with abnormal fetal presentations Close monitoring is needed of the FHR and uterine contraction pattern There are multiple medical and obstetric reasons for inducing labor, the most common being prolonged gestation. Other indications for inductions include PPROM, gestational hypertension, cardiac disease, renal disease, chorioamnionitis, dystocia, intrauterine fetal demise (IUFD), isoimmunization, and diabetes Contraindications to labor induction include complete placenta previa, abruptio placentae, transverse fetal lie, prolapsed umbilical cord, a prior classic uterine incision that entered the uterine cavity, pelvic structure abnormality, previous myomectomy, vaginal bleeding with unknown cause, invasive cervical cancer, active genital herpes infection, and abnormal FHR patterns

Excessive fetal size

Macrosomia, in which a newborn weighs 4,000 to 4,500 g (8.81 to 9.92 lb) or more at birth, complicates approximately 10% of all pregnancies. It is the result of a change in body composition in the neonate with an increase in both percentage of fat and fat mass. Macrosomia is associated with later life obesity, diabetes, and cardiovascular disease Fetal abnormalities may include hydrocephalus, ascites, or a large mass on the neck or head. Complications associated with dystocia related to excessive fetal size and anomalies include an increased risk for postpartum hemorrhage, shoulder dystocia, low Apgar scores, dysfunctional labor, fetopelvic disproportion, soft tissue laceration during vaginal birth, fetal injuries or fractures, and perinatal asphyxia

Forceps or vacuum assisted birth

May be used to apply traction to the fetal head or to provide a method of rotating the fetal head during birth. Forceps are stainless-steel instruments, similar to tongs, with rounded edges that fit around the fetus's head. Outlet forceps are used when the fetal head is crowning and low forceps are used when the fetal head is at a +2 station or lower but not yet crowning. The forceps are applied to the sides of the fetal head. A vacuum extractor is a cup-shaped instrument attached to a suction pump used for extraction of the fetal head The suction cup is placed against the occiput of the fetal head. The pump is used to create negative pressure (suction) of approximately 50 to 60 mm Hg. The birth attendant then applies traction until the fetal head emerges from the vagina. The indications for the use of either method are similar and include a prolonged second stage of labor, a distressed FHR pattern, failure of the presenting part to fully rotate and descend in the pelvis, limited sensation and inability to push effectively due to the effects of regional anesthesia, presumed fetal jeopardy or fetal distress, maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, or infection. Maternal trauma may include lacerations of the cervix, vagina, or perineum; hematoma; extension of the episiotomy incision into the anus; hemorrhage; and infection. Potential newborn trauma includes ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum For forceps or a vacuum extractor to be applied, the following criteria need to be met: membranes ruptured, cervix completely dilated, fetus vertex and engaged, and an adequate maternal pelvis size. Preventive measures include frequently changing the client's position, encouraging ambulation if permitted, frequently reminding the client to empty her bladder to allow maximum space for birth, and providing adequate hydration throughout labor. Additional measures include assessing maternal vital signs, the contraction pattern, the fetal status, and the maternal response to the procedure.

Nursing management of placenta previa

Monitor maternal vital signs, intake and output, vaginal bleeding, and physiologic status for signs of hemorrhage, shock, or infection; closely monitor fetal heart tones for distress (e.g., bradycardia, tachycardia, baseline changes); and treat fetal distress, as ordered. Administer prescribed intravenous fluids, packed red blood cells platelets, and frozen plasma for transfusion, if ordered; Rho(D) immune globulin, if the client is Rh negative; intravenous-augmented oxytocin (Pitocin) to induce labor, if needed; and in cases of preterm labor, tocolytics (e.g., magnesium sulfate) to inhibit uterine contractions and corticosteroids (e.g., betamethasone) to enhance fetal lung maturity. Follow facility pre- and postsurgical protocols if woman becomes a surgical candidate (e.g., for cesarean section); reinforce pre- and postsurgical education and ensure completion of facility's informed consent documents; closely monitor postsurgically for bleeding, infection, and other complications; assess client's anxiety level and coping ability; and provide emotional support and reassurance.

Nursing management of preterm labor

Nursing tasks include monitoring vital signs, measuring intake and output, encouraging bed rest on the woman's left side to enhance placental perfusion, monitoring the FHR via an external monitor continuously, limiting vaginal examinations to prevent an ascending infection, and monitoring the mother and fetus closely for any adverse effects from the tocolytic agents. The primary goals of tocolytic therapy are to arrest labor and delay birth long enough to initiate prophylactic corticosteroid therapy when indicated for stimulation of fetal lung maturity and to arrange for maternal-fetal transport to a perinatal tertiary care hospital. Diagnosis requires the presence of both uterine contractions and cervical change (or an initial cervical examination of more than 2 cm and/or more than 80% effacement in a nulliparous client). Absolute contraindications to administering tocolytic agents to stop labor include intrauterine infection, active hemorrhage, fetal distress, fetus before viability, fetal abnormality incompatible with life, fetal growth restriction, severe preeclampsia, heart disease, prolonged premature rupture of the membranes (PPROM), and intrauterine demise Bed rest and hydration are commonly recommended Presently, women at high risk for preterm labor are offered progesterone therapy at the start of their second trimester. Magnesium sulfate may be ordered. This agent acts as a physiologic calcium antagonist and a general inhibitor of neurotransmission. Expect to administer it intravenously. Monitor the woman for nausea, vomiting, headache, weakness, hypotension, and cardiopulmonary arrest. Frequent monitoring of maternal respiratory effort and deep tendon reflexes is essential for early recognition of overdose. Because magnesium is exclusively excreted by the kidneys, adequate renal function is essential for safe administration. Assess the fetus for decreased FHR variability, drowsiness, and hypotonia. Calcium channel blockers promote uterine relaxation by decreasing the influx of calcium ions into myometrium cells to inhibit contractions. Administer calcium channel blockers (nifedipine) orally or sublingually every 4 to 8 hours as ordered. Monitor the woman for hypotension, reflex tachycardia, headache, nausea, and facial flushing. Prostaglandin synthetase inhibitor (indomethacin [Indocin]) reduces prostaglandin synthesis from decidual macrophages. It readily crosses the placenta and can cause oligohydramnios due to a decrease in fetal renal blood flow if used for more than 48 hours. During treatment, urine output, maternal temperature, and amniotic fluid index (AFI) should be evaluated periodically. The initial recommended dose is 50 to 100 mg orally or per rectum followed by 25 to 50 mg every 6 hours for 8 doses. Indomethacin therapy is not recommended for gestations of 32 weeks or greater

Nursing assessment of postterm pregnancy

Obtain a thorough history to determine the estimated date of birth. When expectant management is chosen versus labor induction for the postterm pregnancy, the nurse should anticipate that assessments for a postterm pregnancy will typically include daily fetal movement counts done by the woman, nonstress tests with amniotic fluid assessments as part of the biophysical profile done twice weekly, and weekly cervical examinations to evaluate for ripening. Induction can be deferred until 42 weeks if the fetal surveillance is reassuring. In addition, assess the following: Client's understanding of the various fetal well-being tests Client's stress and anxiety concerning her lateness Client's coping ability and support network

hypotonic uterine dysfunction

Occurs during active labor (dilation more than 5 to 6 cm) when contractions become poor in quality and lack sufficient intensity to dilate and efface the cervix. Factors associated with this abnormal labor pattern include overstretching of the uterus, a large fetus, multiple fetuses, hydramnios, multiple parity, bowel or bladder distention preventing descent, and excessive use of analgesia. Clinical manifestations of hypotonic uterine dysfunction include weak contractions that become milder, a uterine fundus that can be easily indented with fingertip pressure at the peak of each contraction, and contractions that become more infrequent and briefer The major risk with this complication is hemorrhage after giving birth because the uterus cannot contract effectively to compress blood vessels.

Nursing management of umbilical cord prolapse

Often the first sign of cord prolapse is a sudden fetal bradycardia or recurrent variable decelerations that become progressively more severe. Call for help immediately and do not leave the woman. When membranes are artificially ruptured, assist with verifying that the presenting part is well applied to the cervix and engaged into the pelvis. If pressure or compression of the cord occurs, assist with measures to relieve the compression. Typically, the examiner places a sterile gloved hand into the vagina and holds the presenting part off the umbilical cord until delivery. Changing the woman's position to a modified Sims, Trendelenburg, or knee-chest position also helps relieve cord pressure. Do not attempt to replace the cord in the uterus. Monitor FHR, maintain bed rest, and administer oxygen if ordered. Provide emotional support and explanations as to what is going on to allay the woman's fears and anxiety. If the mother's cervix is not fully dilated, prepare the woman for an emergency cesarean birth to save the fetus's life if that is the intervention planned for by her health care provider.

Amnioinfusion

A technique in which a volume of warmed, sterile, normal saline or Ringer lactate solution is introduced into the uterus transcervically through an intrauterine pressure catheter to increase the volume of fluid when oligohydramnios is present. It is a procedure used during labor. It is used to change the relationship of the uterus, placenta, cord, and fetus to improve placental and fetal oxygenation. Instilling an isotonic glucose-free solution into the uterus helps to cushion the umbilical cord to prevent compression or dilute thick meconium. This procedure is commonly indicated for severe variable decelerations due to cord compression, oligohydramnios due to placental insufficiency, postmaturity or rupture of membranes, preterm labor with premature rupture of membranes, and thick meconium fluid. Contraindications to amnioinfusion include vaginal bleeding of unknown origin, umbilical cord prolapse, amnionitis, uterine hypertonicity, and severe fetal distress After obtaining informed consent, a vaginal examination is performed to evaluate for cord prolapse, establish dilation, and confirm presentation. Next, 250 to 500 mL of warmed normal saline or lactated Ringer solution is administered using an infusion pump over 20 to 30 minutes. Overdistention of the uterus is a risk, so the amount of fluid infused must be monitored closely. Amnioinfusion should reach therapeutic result or increase the amniotic fluid volume in approximately 30 minutes When caring for the woman who is receiving an amnioinfusion, include the following: Explain the need for the procedure, what it involves, and how it may solve the problem. Inform the mother that she will need to remain on bed rest during the procedure. Assess the mother's vital signs and associated discomfort level. Maintain intake and output records. Assess the duration and intensity of uterine contractions frequently to identify overdistention or increased uterine tone. Assess for fluid leakage by evaluating the chuck or pad under the woman to determine that it is not being retained in the uterus, which could lead to increased uterine pressure. Monitor the FHR pattern to determine whether the amnioinfusion is improving the fetal status. Prepare the mother for a possible cesarean birth if the FHR does not improve after the amnioinfusion.

Nursing assessment of intrauterine fetal demise

A woman experiencing an IUFD is likely to seek care when she notices that the fetus is not moving or when she experiences contractions, loss of fluid, or vaginal bleeding. An inability to obtain fetal heart sounds on examination suggests fetal demise, but an ultrasound is necessary to confirm the absence of fetal cardiac activity. Once fetal demise is confirmed, induction of labor or expectant management is offered to the woman.

Vaginal Birth After Cesarean

A woman who gives birth vaginally after having at least one previous cesarean birth. Contraindications to VBAC include a prior classic uterine incision, prior transfundal uterine surgery (myomectomy), uterine scar other than low-transverse cesarean scar, contracted pelvis, and inadequate staff or facility if an emergency cesarean birth in the event of uterine rupture is required The use of cervical ripening agents increases the risk of uterine rupture and thus is contraindicated in VBAC clients. Management is similar for any women experiencing labor, but certain areas require special focus: Consent: Fully informed consent is essential for the woman who wants to have a trial of labor after cesarean birth. The client must be advised about the risks as well as the benefits. She must understand the ramifications of uterine rupture, even though the risk is small. Documentation: Record keeping is an important component of safe client care. If and when an emergency occurs, it is imperative to take care of the client, but also to keep track of the plan of care, interventions and their timing, and the client's response. Events and activities can be written right on the fetal monitoring tracing to correlate with the change in fetal status. Surveillance: A distressed fetal monitor tracing in a woman undergoing a trial of labor after a cesarean birth should alert the nurse to the possibility of uterine rupture. Terminal bradycardia must be considered an emergency situation, and the nurse should prepare the team for an emergency delivery. Readiness for emergency: According to ACOG (2010) criteria for a safe trial of labor for a woman who has had a previous cesarean birth, the physician or nurse practitioner, anesthesia provider, and operating room team must be immediately available. Anything less would place the women and fetus at risk.

Placenta previa

Placental implantation in the lower uterine segment over or near the internal os of the cervix, typically during the second or third trimester of pregnancy. With uterine segment formation and cervical dilation, placental implantation over or near the cervical os, instead of along the uterine wall, inevitably results in spontaneous placental separation—and subsequent hemorrhage. This position can create a barrier for the fetus from the uterus during the birthing process. As the cervix begins to thin and dilate (open up) in preparation for labor, blood vessels that connect the placenta to the uterus may tear and cause bleeding. It is the most common cause of bleeding in the second half of pregnancy and should be suspected in any woman beyond 24 weeks' gestation presenting with vaginal bleeding; ultrasonography (e.g., transvaginal) is used to diagnose it. During labor and birth, bleeding can be severe, which can place the mother and fetus at risk. There is a direct relationship between the number of previous cesarean births and the risk of placenta previa, probably due to uterine scarring. Risk factors for placenta previa include previous cesarean section, advanced maternal age >34, multiparity, multiple gestation, prior placenta previa, and cigarette smoking Maternal signs and symptoms of placenta previa include sudden, painless bleeding (that may be heavy enough to be considered hemorrhaging), anemia, pallor, hypoxia, low blood pressure, tachycardia, soft and nontender uterus, and rapid, weak pulse. Bleeding may be episodic, with spontaneous initiation and cessation; in some cases, it is asymptomatic because there is intrauterine bleeding only without external signs. Management of placenta previa varies by type and gestational age, and frequent medical surveillance may be sufficient in marginal cases; prompt treatment with bed rest, close monitoring, and control/replacement of blood loss greatly reduces risk for maternal and fetal complications and death. Vaginal delivery is possible when bleeding is minimal, placenta previa is marginal, or labor is rapid. Pregnancy termination, early birth by cesarean section, or a hysterectomy may be necessary in order to control severe bleeding, especially for clients with complete placenta previa

Nursing assessment of amniotic fluid embolism

Predisposing factors associated with AFE include placental abruption, uterine over distention, fetal demise, uterine trauma, oxytocin-stimulated labor, amnioinfusion, multiparity, advanced maternal age, and ruptured membranes. No test can diagnose an AFE. Immediate recognition and diagnosis of this condition are essential to improve maternal and fetal outcomes. The clinical appearance is varied, but most women report difficulty breathing. Other symptoms include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, disseminated intravascular coagulation (DIC), pulmonary edema, seizures, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest

Placental abruption

Premature separation of a normally implanted placenta from the maternal myometrium. Risk factors include preeclampsia, gestational hypertension, seizure activity, advanced maternal age >34, uterine rupture, trauma, smoking, cocaine use, coagulation defects, chorioamnionitis, premature rupture of membranes, hydramnios, uterine trauma, external cephalic version for breech presentation, previous history of abruption, domestic violence, and placental pathology. These conditions may force blood into the underlayer of the placenta and cause it to detach Typically once the diagnosis is established, the focus is on maintaining the cardiovascular status of the mother and developing a plan to deliver the fetus quickly. A cesarean birth may take place quickly if the fetus is still alive with only a partial abruption. A vaginal birth may take place if there is fetal demise secondary to a complete abruption.

Problems with the passageway

Problems with the passageway (pelvis and birth canal) are related to a contraction of one or more of the three planes of the maternal pelvis: inlet, midpelvis, and outlet. Contraction of the midpelvis is more common than inlet contraction and typically causes an arrest of fetal descent. Obstructions in the maternal birth canal, such as swelling of the soft maternal tissue and cervix, termed soft tissue dystocia, also can hamper fetal descent and impede labor progression outside the maternal bony pelvis.

Therapeutic management of labor induction

The decision to induce labor is based on a thorough evaluation of maternal and fetal status. Typically, this includes an ultrasound to evaluate fetal size, position, and gestational age and to locate the placenta; engaged presenting fetal part; pelvimetry to rule out fetopelvic disproportion; a nonstress test to evaluate fetal well-being; a phosphatidylglycerol (PG) level to assess fetal lung maturity; confirmation of category I FHR pattern; complete blood count and urinalysis to rule out infection; and a vaginal examination to evaluate the cervix for inducibility

Nursing management of dystocia

The nurse should provide physical and emotional support to the client and her family. Continue to assess the woman, frequently monitoring cervical dilation and effacement, uterine contractions, and fetal descent, and document that all assessed parameters are progressing. Evaluate progress in active labor by using the simple rule of 1 cm per hour for cervical dilation. When the woman's membranes rupture, if they have not already ruptured, observe for visible cord prolapse. Throughout labor, assess the woman's fluid balance status. Check skin turgor and mucous membranes. Monitor intake and output. Also monitor the client's bladder for distention at least every 2 hours and encourage her to empty her bladder often. In addition, monitor her bowel status. A full bladder or rectum can impede descent. Continue to monitor fetal well-being. If the fetus is in the breech position, be especially observant for visible cord prolapse and note any variable decelerations in heart rate. If either occurs, report it immediately. Be prepared to administer a labor stimulant such as oxytocin (Pitocin) if ordered to treat hypotonic labor contractions. Anticipate the need to assist with manipulations if shoulder dystocia is diagnosed. Prepare the woman and her family for the possibility of a cesarean birth if labor does not progress. Offer blankets for warmth and a backrub, if the client wishes, to reduce muscle tension. Provide an environment conducive to rest so the woman can conserve her energy. Lower the lights and reduce external noise by closing the hallway door. Offer a warm shower to promote relaxation (if not contraindicated). Use pillows to support the woman in a comfortable position, changing her position every 30 minutes to reduce tension and to enhance uterine activity and efficiency. Offer her fluids/food as appropriate to moisten her mouth and replenish her energy Upright positions are helpful in facilitating fetal rotation and descent. Also encourage the woman to visualize the descent and birth of the fetus. Assess the woman's level of pain and degree of distress. Administer analgesics as ordered or according to the facility's protocol.

Shoulder dystocia

The obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. It is an obstetric emergency that requires a coordinated team response, as there is no reliable way to predict it, and thus decrease the rate at which adverse outcomes occur Postpartum hemorrhage, secondary to uterine atony, vaginal lacerations, anal tears, and uterine rupture are major complications to the mother. Transient Erb or Duchenne brachial plexus palsies and clavicular or humeral fractures are the most common fetal injuries encountered with shoulder dystocia. Newborns experiencing shoulder dystocia typically have greater shoulder-to-head and chest-to-head disproportions compared with those delivered without dystocia Prompt recognition and appropriate management, such as with McRoberts maneuver or suprapubic pressure, can reduce the severity of injuries to the mother and newborn

Preterm labor

The occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation. If not halted, it leads to preterm birth.

Cesarean birth

The surgical birth of the fetus through an incision in the abdomen and uterine wall The leading indications for cesarean births are previous cesarean birth, breech presentation, dystocia, and fetal distress. Once a woman has experienced a primary cesarean birth, she has a 90% chance of having another one in a subsequent pregnancy The client is at risk for complications such as infection, hemorrhage, aspiration, pulmonary embolism, urinary tract trauma, thrombophlebitis, paralytic ileus, and atelectasis. Fetal injury and transient tachypnea of the newborn also may occur Spinal, epidural, or general anesthesia is used for cesarean births. Epidural anesthesia is most commonly used because it is associated with less risk and most women wish to be awake and aware of the birth experience

Problems with the Psyche

These emotions can lead to psychological stress, which indirectly can cause dystocia. Hormones released in response to anxiety can cause dystocia. Intense anxiety stimulates the sympathetic nervous system, which releases catecholamines that can lead to myometrial dysfunction. Norepinephrine and epinephrine then lead to uncoordinated or increased uterine activity

Persistent occiput posterior position

This position presents slightly larger diameters to the maternal pelvis, thus slowing fetal descent. A fetal head that is poorly flexed may be responsible. In addition, poor uterine contractions may not push the fetal head down into the pelvic floor to the extent that the fetal occiput sinks into it rather than being pushed to rotate in an anterior direction.

Therapeutic management of preterm labor

Tocolytic therapy is most likely ordered if preterm labor occurs before the 34th week of gestation in an attempt to delay birth and thereby to reduce the severity of respiratory distress syndrome and other complications associated with prematurity. Tocolytic therapy does not typically prevent preterm birth, but it may delay it. It is contraindicated for abruptio placentae, acute fetal distress or death, eclampsia or severe preeclampsia, active vaginal bleeding, dilation of more than 6 cm, chorioamnionitis, and maternal hemodynamic instability Medications commonly used for tocolysis include magnesium sulfate (which reduces the muscle's ability to contract), indomethacin (Indocin, a prostaglandin synthetase inhibitor), atosiban (Tractocile, Antocin, an oxytocin receptor antagonist), and nifedipine (Procardia, a calcium channel blocker) Corticosteroids given to the mother in preterm labor can help prevent or reduce the frequency and severity of respiratory distress syndrome in premature infants delivered between 24 and 34 weeks' gestation. The beneficial effects of corticosteroids on fetal lung maturation have been reported within 48 hours of initial administration. They supported the use of repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth 7 days or more after an initial course. These benefits were associated with a small reduction in size at birth These drugs require at least 24 hours to become effective, so timely administration is crucial.

Cervical Length Measurement

Transvaginal ultrasound of the cervix has been used as a tool to predict preterm labor in high-risk pregnancies and to differentiate between true and false preterm labor. Three parameters are evaluated during the transvaginal ultrasound: cervical length and width, funnel width and length, and percentage of funneling. Measurement of the closed portion of the cervix visualized during the transvaginal ultrasound is the single most reliable parameter for prediction of preterm delivery in high-risk women A cervical length of 3 cm or more indicates that delivery within 14 days is unlikely. Women with a short cervical length of 2.5 cm during the mid trimester have a substantially greater risk of preterm birth prior to 35 weeks' gestation. As with fetal fibronectin testing, negative results can be reassuring and prevent unnecessary interventions

Nursing management of uterine rupture

Urgent delivery by cesarean birth is usually indicated. Monitor maternal vital signs and observe for hypotension and tachycardia, which might indicate hypovolemic shock. Assist in preparing for an emergency cesarean birth by alerting the operating room staff, anesthesia provider, and neonatal team. Insert an indwelling urinary (Foley) catheter if one is not in place already. Inform the woman of the seriousness of this event and remind her that the health care staff will be working quickly to ensure her health and that of her fetus. Remain calm and provide reassurance that everything is being done to ensure a safe outcome for both. The life-threatening nature of uterine rupture is underscored by the fact that the maternal circulatory system delivers approximately 500 mL of blood to the term uterus every minute Maternal death is a real possibility without rapid intervention. Newborn outcome after rupture depends largely on the speed with which surgical rescue is carried out.

Nursing management of postterm pregnancy

When determining the plan of care for a woman with a prolonged pregnancy, the first decision is whether to deliver the baby or wait. If the decision is to wait, then fetal surveillance is key. If the decision is to have the woman give birth, labor induction is initiated. Provide reassurance about the expected time range for birth and the well-being of the fetus based on the assessment tests. Teach the woman and her partner about the testing required and the reasons for each test. Also describe the methods that may be used for cervical ripening if indicated. Explain about the possibility of induction if the woman's labor is not spontaneous or if a dysfunctional labor pattern occurs. Also prepare the woman for the possibility of a surgical delivery if fetal distress occurs. During the intrapartum period, continuously assess and monitor FHR to identify potential fetal distress early (e.g., late or variable decelerations) so that interventions can be initiated. Also monitor the woman's hydration status to ensure maximal placental perfusion. When the membranes rupture, assess amniotic fluid characteristics (color, amount, and odor) to identify previous fetal hypoxia and prepare for prevention of meconium aspiration. Report meconium-stained amniotic fluid immediately when the woman's membranes rupture. Anticipate the need for amnioinfusion to minimize the risk of meconium aspiration by diluting the meconium in the amniotic fluid expelled by the hypoxic fetus. In addition, monitor the woman's labor pattern closely because dysfunctional patterns are common

Precipitate labor

When the uterus contracts so frequently and with such intensity that a very rapid birth will take place Labor that is completed in less than 3 hours from the start of contractions to birth. Maternal complications are rare if the maternal pelvis is adequate and the soft tissues yield to a fast fetal descent. However, if the fetus delivers too fast, it does not allow the cervix to dilate and efface, which leads to cervical lacerations and the potential for uterine rupture. Potential fetal complications may include head trauma, such as intracranial hemorrhage or nerve damage, and hypoxia due to the rapid progression of labor

Protracted disorders

a series of events including protracted active phase dilation (slower than normal rate of cervical dilation) and protracted descent (delayed descent of the fetal head in the active phase). Most women, however, benefit greatly from adequate hydration and some nutrition, emotional reassurance, and position changes—these women may go on and give birth vaginally.

Dystocia

abnormal or difficult labor it is characterized by a slow and abnormal progression of labor. It is usually during the active phase that dystocia becomes apparent.

Face and brow presentation

associated with fetal abnormalities (anencephaly), pelvic contractures, high parity, placenta previa, hydramnios, low birth weight, or a large fetus

Arrest disorders

complete cessation of uterine contractions

Indications for cesarean births

labor dystocia abnormal fetal heart rate (FHR) tracing fetal malpresentation multiple gestation suspected macrosomia

hypertonic uterine dysfunction

occurs when the uterus never fully relaxes between contractions. Subsequently, contractions are ineffectual, erratic, and poorly coordinated because they involve only a portion of the uterus and because more than one uterine pacemaker is sending signals for contraction. Women in this situation experience a prolonged latent phase, stay at 2 to 3 cm, and do not dilate as they should. Placental perfusion becomes compromised, thereby reducing oxygen to the fetus. These hypertonic contractions exhaust the mother, who is experiencing frequent, intense, and painful contractions with little progression. This dysfunctional pattern occurs in early labor and affects nulliparous women more than multiparous women

Postterm pregnancy

one that continues past the end of the 42nd week of gestation, or 294 days from the first day of the last menstrual period. Maternal risk is related to the large size of the fetus at birth, which increases the chances that a cesarean birth will be needed. Other issues might include dystocia, birth trauma, postpartum hemorrhage, and infection. Mechanical or artificial interventions such as forceps or vacuum-assisted birth and labor induction with oxytocin may be necessary. In addition, maternal exhaustion and feelings of despair over this prolonged gestation can add to the woman's anxiety level and reduce her coping ability. Fetal risks associated with a postterm pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of subcutaneous fat and muscle and meconium staining), and cephalopelvic disproportion. All of these conditions predispose this fetus to birth trauma or a surgical birth As the placenta ages, its perfusion decreases and it becomes less efficient at delivering oxygen and nutrients to the fetus. Amniotic fluid volume also begins to decline after 38 weeks of gestation, possibly leading to oligohydramnios, subsequently resulting in fetal hypoxia and an increased risk of cord compression because the cushioning effect offered by adequate fluid is no longer present. Hypoxia and oligohydramnios predispose the fetus to aspiration of meconium, which is released by the fetus in response to a hypoxic insult

Multiple gestation

refers to twins, triplets, or more infants within a single pregnancy The most common maternal complication is postpartum hemorrhage resulting from uterine atony. Compared with singletons (one fetus), the risk of perinatal morbidity and mortality is markedly increased in multiple gestations. As long as the presenting twin is vertex, a vaginal birth should be considered

breech presentation

when the buttocks or feet presenting By 35 to 36 weeks' gestation, the majority of fetuses will spontaneously settle into the vertex presentation This presentation frequently is associated with multifetal or multiple pregnancies, grand multiparity (more than five births), pregnancy over age 35 (advanced maternal age), placenta previa, hydramnios, preterm births, uterine malformations or fibroids, a scarred uterus, a female infant, and fetal anomalies such as hydrocephaly An increased frequency of prolapsed cord, placenta previa, low birth weight from preterm birth, fetal or uterine anomalies, and perinatal morbidity and mortality from a difficult birth may occur A breech presentation may be an indicator for subtle fetal abnormalities, as apparently healthy breech infants have on average poorer long-term neurodevelopmental scores than cephalic infants

Nursing assessment of labor induction

Review the woman's history for relative indications for induction or augmentation, such as diabetes, hypertension, postterm status, dysfunctional labor pattern, prolonged ruptured membranes, and maternal or fetal infection, and for contraindications such as placenta previa, overdistended uterus, active genital herpes, fetopelvic disproportion, fetal malposition, or severe fetal distress. Assist with determining the gestational age of the fetus to prevent a preterm birth. Assess fetal well-being to validate the client's and fetus's ability to withstand labor contractions. Evaluate the woman's cervical status, including cervical dilation and effacement, and station via vaginal examination as appropriate before cervical ripening or induction is started. Determine the Bishop score to determine the probable success of induction.

Nursing management of intrauterine fetal demise

Provide accurate, understandable information to the family. Acknowledge that the woman's feeling of loss are legitimate. Reassure mother that there was likely nothing that she could have done to prevent it. Be knowledgeable about the grief process and comfortable in sharing another's grief. Utilize active listening to provide needed encouragement to the family members to open up to their feelings. Create a warm, receptive, accepting, and caring environment conducive to dialogue. Dispel guilt by saying that nothing the woman did caused the fetal death. Acknowledge their grief by saying that their feeling sad is appropriate. Recognize that each family member may express their grief differently. Provide reassurance about successful future pregnancies. Encourage discussion of the loss and venting of feelings of grief and guilt. Provide the family with baby mementos and pictures to validate the reality of death. Allow unlimited time with the stillborn infant after birth to validate the death; provide time for the family members to be together and grieve; offer the family the opportunity to see, touch, and hold the infant. Use appropriate touch, such as holding a hand or touching a shoulder. Inform the chaplain or the religious leader of the family's denomination about the death and request his or her presence. Assist the parents with the funeral arrangements or disposition of the body. Provide the parents with brochures offering advice about how to talk to other siblings about the loss. Refer the family to the support group SHARE Pregnancy and Infant Loss Support, Inc., which is designed for those who have lost an infant through abortion, miscarriage, fetal death, stillbirth, or other tragic circumstances. Make community referrals to promote a continuum of care after discharge.

Nursing assessment of dystocia

Review the client's history to look for risk factors for dystocia which may include maternal short stature, obesity, hydramnios, uterine abnormalities, fetal malpresentation, cephalopelvic disproportion, over stimulation with oxytocin, maternal exhaustion, ineffective pushing, excessive size fetus, poor maternal positioning in labor, and maternal anxiety and fear Assess the woman's vital signs. Note any elevation in temperature (might suggest an infection) or changes in heart rate or blood pressure (might signal hypovolemia). Evaluate the uterine contractions for frequency and intensity. Question the woman about any changes in her contraction pattern, such as a decrease or increase in frequency or intensity, and report these. Assess FHR and pattern, reporting any abnormal patterns immediately. Assess fetal position via Leopold maneuversto identify any deviations in presentation or position, and report any deviations. Assist with or perform a vaginal examination to determine cervical dilation, effacement, and engagement of the fetal presenting part. Evaluate for evidence of membrane rupture. Report any malodorous fluid.

Nursing assessment of uterine rupture

Review the mother's history for risk conditions such as uterine scars, prior cesarean births, prior rupture, trauma, prior invasive molar pregnancy, history of placenta percreta or increta, congenital uterine anomalies, multiparity, previous uterine myomectomy, malpresentation, labor induction with excessive uterine stimulation, and crack cocaine use Generally, the first and most reliable symptom of uterine rupture is sudden fetal distress. Other signs may include acute and continuous abdominal pain with or without an epidural, vaginal bleeding, hematuria, irregular abdominal wall contour, loss of station in the fetal presenting part, and hypovolemic shock in the woman, fetus, or both