Ricci chapter 21

Dystocia causes passenger

* Any presentation other than occiput anterior (head down and anterior facing) or a slight variation of the fetal position or size increases the probability of dystocia. * Occiput posterior position - most common cause of dystocia. 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. * Breech presentation -only occurs in 3 to 4 % of fetuses increases risk for prolapse when feet are presenting can occur with placenta previa in this situation you hope baby turns on its own if not external eversion is performed 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 (Sharshiner & Silver, 2015). In a persistent breech presentation, 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 (Cunningham et al., 2014). 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 (Hofmeyr, 2015). Perinatal mortality is increased two- to fourfold with a breech presentation, regardless of the mode of delivery. * Multifetal 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. Based on recent level 1 evidence from a randomized-controlled study, it was found that there was no difference in newborn outcomes between a planned surgical birth versus a planned vaginal birth for twins between 32 to 39 weeks of gestation. As long as the presenting twin is vertex, a vaginal birth should be vaginal * Macrosomia and CPD - in cpd the head is too big for the pelvis. Macrosomia is associated with later life obesity, diabetes, and cardiovascular disease (Jazayeri, 2015). 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 * Structural abnormalities (see Table 21.1) * Face and brow presentations are rare and are associated with fetal abnormalities (anencephaly), pelvic contractures, high parity, placenta previa, hydramnios, low birth weight, or a large fetus * Shoulder dystocia is defined as the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. The incidence of shoulder dystocia is increasing due to increasing birth weight, with reports of it in up to 2% of vaginal births. 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 (Gherman, 2015). It is one of the most anxiety-provoking emergencies encountered in labor. Failure of the shoulders to deliver spontaneously places both the woman and the fetus at risk for injury. Postpartum hemorrhage, secondary to uterine atony, vaginal lacerations, anal tears, and uterine rupture are major complications to the mother. Transient Erb's or Duchenne's brachial plexus palsies and clavicular or humeral fractures are the most common fetal injuries encountered with shoulder dystocia (Ricci 765) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Intrauterine fetal demise

* Numerous causes - * Devastating effects on family and staff * Nursing assessment * Inability to obtain fetal heart sounds * Ultrasound to confirm absence of fetal activity * Labor induction * Nursing management * Assistance with grieving process * Referrals

Cessarian birth

* Classic or low transverse incision (see Figure 21.8) * Major surgical procedure with accompanying risks * Nursing assessment: history and physical examination for maternal and fetal indications * 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 (Joy & Contag, 2015). (Ricci 792) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. * Nursing management * Preoperative care -Client preparation varies depending on whether the cesarean birth is planned or unplanned. The major difference is the time allotted for preparation and teaching. In an unplanned cesarean birth, institute measures quickly to ensure the best outcomes for the mother and fetus. Ensure that the woman has signed an informed consent, and allow for discussion of fears and expectations. Provide essential teaching and explanations to reduce the woman's fears and anxieties. * Ascertain the client's and family's understandings of the surgical procedure. Reinforce the reasons for surgery given by the surgeon. Outline the procedure and expectations of the surgical experience. Ensure that all diagnostic tests ordered have been completed, and evaluate the results. Explain to the woman and her family about what to expect postoperatively. Reassure the woman that pain management will be provided throughout the procedure and afterward. 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. * Provide preoperative teaching to reduce the risk of postoperative complications. 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 * Maintain a calm, confident manner in all interactions with the client and family. Help transport the client and her partner to the operative area. * * Postoperative care- Postoperative care for the mother who has had a cesarean delivery is similar to that for one who has had a vaginal birth, with a few additional measures. 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. * Encourage early touching and holding of the newborn to promote bonding. Promote family unity and bonding. Assist with breast-feeding initiation and offer continued support. Suggest alternate positioning techniques to reduce incisional discomfort while breast-feeding. (See Chapter 18 for breast-feeding positions.) * Review with the couple their perception of the surgical birth experience. Allow them to verbalize their feelings and assist them in positive coping measures. Promote a positive emotional response to the birth experience and parenting role. Prior to discharge, teach the woman about the need for adequate rest, activity restrictions such as lifting, and signs and symptoms of infection. Provide information about postpartum care at home upon discharge. (Ricci 792-794) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Vbac and oxytocin

* Controversy related to risk of uterine rupture and hemorrhage * Contraindications -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 (Ricci 784) * Special areas of focus: consent, documentation, surveillance, and readiness for emergency * Nurses as advocates for clients; expertise in reading fetal monitoring tracings to identify nonreassuring pattern and instituting measures for emergency delivery Oxytocin Oxytocin is 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. Frequently, a woman with an unfavorable cervix is admitted the evening before induction to ripen her cervix with one of the prostaglandin agents. Then induction begins with oxytocin the next morning if she has not already gone into labor. Doing so markedly enhances the success of induction. Response to oxytocin varies widely: some women are very sensitive to even small amounts. The most common adverse effect of oxytocin is uterine hyperstimulation, leading to fetal compromise and impaired oxygenation (King, et al., 2015). 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 are 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. Recent studies suggest that a more conservative oxytocin protocol with lower doses reduces the number of neonatal intensive care unit admissions and lower cesarean sections (Lewis et al., 2014; Manjula et al., 2015). The uterus should relax between contractions. If the resting uterine tone remains above 20 mm Hg, uteroplacental insufficiency and fetal hypoxia can result. This underscores the importance of continuous FHR monitoring. Unfortunately, neither the optimal oxytocin administration regimen nor the maximum oxytocin dose has been established or agreed upon through research or expert opinion. Nurses assisting with labor inductions need to become familiar with their hospital protocols concerning dosage, infusion rates, and frequency of change. 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 (Arrowsmith & Wray, 2014) (Fig. 21.4). (Ricci 780) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Placental abruption

* Obstetric emergency involving premature separation * Risk factors -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 (Deering, 2015). (Ricci 788) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. * Management dependent on gestational age, extent of hemorrhage, and maternal-fetal oxygenation perfusion * Maintenance of maternal cardiovascular status * Prompt delivery of fetus * Cesarean birth if fetus still alive; vaginal birth if fetal demise

Dystocia causes passageway

* Pelvic contraction - most often midpelvis contracts and slows fetal descent. * Obstructions in maternal birth canal - when there is something obstructing the fetus

Dystocia causes (powers)

* Problems with powers * Hypertonic uterine dysfunction - pain on contractions but does not relax contractions are painful and intense. 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 (Ricci 758) * Hypotonic uterine dysfunction - poor uterine contractions that are not strong enough to dilate the cervix 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 (King et al., 2015). The major risk with this complication is hemorrhage after giving birth because the uterus cannot contract effectively to compress blood vessels * Protracted disorders - refers to 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). A laboring woman with a slower than normal rate of cervical dilation is said to have a protraction labor pattern disorder. A slow progress may be the result of cephalopelvic disproportion. 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. * Arrest disorders - include secondary arrest of dilation (no progress in cervical dilation in >2 hours), arrest of descent (fetal head does not descend for more than 1 hour in primip and more that 0.5 hour in multip), and failure of descent (no descent). * Precipitate labor - a labor that is completed in less than 3 hours from the start of contractions to birth. Not only can labor be too slow, but it can be abnormally rapid. The prevailing opinion has been that too rapid a labor can result in maternal injury and place the fetus at risk for traumatic or asphyxia insults (Suzuki, 2015). Women experiencing precipitate labor typically have soft perineal tissues that stretch readily, permitting the fetus to pass through the pelvis quickly, or abnormally strong uterine contractions. 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 Precipitate labor is an anxiety-producing situation and frequently very painful with little rest between contractions. Continuous monitoring, frequent updates on her labor progress, pain management, and reassurance about her condition can assist in reducing the mother's anxious state of mind remember to ready the health care team * Problems with the passageway * Pelvic contraction - most often midpelvis contracts and slows fetal descent. * Obstructions in maternal birth canal - when there is something obstructing the fetus

Lab tests for preterm labor

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., Fetal fibronectin and cervical length examinations have a high negative predictive value and are thus better at predicting which pregnant women are unlikely to have a preterm birth as opposed to predicting those who will (van Baaren et al., 2015). 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 >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 (Abbott et al., 2015). 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. Fibronectin testing can be a useful tool in the triaging of women symptomatic for preterm labor. 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 (van Baaren et al., 2014). Cervical length varies during pregnancy and can be measured fairly reliably after 16 weeks of gestation using an ultrasound probe inserted in the vagina. 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 of gestation. As with fetal fibronectin testing, negative results can be reassuring and prevent unnecessary interventions (Souka et al., 2015). Nursing management of preterm birth Preterm birth prevention programs for women at high risk have used self-monitoring of symptoms and patterns, weekly cervical examinations, clinical markers, telephone monitoring, home visiting, alone or in combination, with disappointing results. Preterm labor is currently thought to be a chronic, long-term multifactorial process with a genetic component. A recent study found a multiple pregnancy, prior preterm birth, low socioeconomic status, maternal medical disorders, and maternal infections were statistically significant risk factors for predicting spontaneous preterm labor (Patel, Pitre, & Bhooker, 2015). Despite technologic and pharmacologic advances in the identification and treatment of preterm labor, the incidence remains high and is growing in the United States Supportive nursing care is needed for the woman in preterm labor whether the contractions are stopped with tocolytic therapy or not. 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 fetal heart rate 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. Offering the couple ongoing explanations will help prepare them for the birth.

Educating the client preterm labor

Ensure that every pregnant woman receives basic education about preterm labor, including information about harmful lifestyles, the signs of genitourinary infections and preterm labor, and the appropriate response to these symptoms. Teach the client how to palpate for and time uterine contractions. Provide written materials to support this education at a level and in a language appropriate for the client. Also educate clients about the importance of prenatal care, risk reduction, and recognizing the signs and symptoms of preterm labor. Teaching Guidelines 21.1 highlights important instructions related to preventing preterm labor. (Ricci 774) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Administering tocolytics

Tocolysis is the use of drugs to inhibit uterine contractions. 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. A firm diagnosis of preterm labor is necessary before treatment is considered. 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). A cause for preterm labor should always be sought. 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 (Callahan, 2016). Bed rest and hydration are commonly recommended, but without proven efficacy. Prevention of preterm labor remains an elusive goal. Presently, women at high risk for preterm labor are offered progesterone therapy at the start of their second trimester. Although progesterone therapy is recommended by ACOG, it has not been FDA approved for this purpose and has mixed results (Iams, 2015). p. 773 p. 774 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. Magnesium has a wide margin of safety, but is not any more effective in delaying preterm birth as any other tocolytic agent. However, if administered prenatally, it is effective in helping women who develop preeclampsia and helping to protect fetal brains (Nakazawa et al., 2015). Calcium channel blockers promote uterine relaxation by decreasing the influx of calcium ions into myometrium cells to inhibit contractions. Although calcium channel blockers may be prescribed to manage preterm labor, available literature provides little evidence that they have better efficacy in treating preterm labor than any other tocolytic agent. The perfect tocolytic drug that is 100% efficacious and 100% safe does not exist yet (van den Bosch, Ruys, & Roos-Hesselink, 2015). 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 (Ross, 2015). (Ricci 773-774) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Dystocia

defined as abnormal or difficult labor, can be influenced by a vast number of maternal and fetal factors. Dystocia is said to exist when the progress of labor deviates from normal; it is characterized by a slow and abnormal progression of labor. It occurs in approximately 8% to 11% of all labors and is the leading indicator for primary cesarean birth in the United States (Joy, Lyon, & Scott, 2015). dystocia usually becomes apparent phase of labor. - however cannot be predicted when it will occur Because dystocia cannot be predicted or diagnosed with certainty, the term "failure to progress" is often used. This term includes lack of progressive cervical dilation, lack of descent of the fetal head, or both. An adequate trial of labor is needed to declare with confidence that dystocia or "failure to progress" exists. . The most common indications for primary cesarean births include, in order of frequency, labor dystocia, abnormal fetal heart rate tracing, fetal malpresentation, multiple gestations, and suspected macrosomia Labors today are often longer which may in part be due to higher body mass index (BMI), higher rates of labor induction, and the significant increase in the use of epidural anesthesia (ACOG, 2014a). Admitting women too early to the hospital while still in the early latent phase of labor may increase the diagnosis of dystocia and increase the risk of augmentation of labor and epidural analgesia. These two interventions may cascade into a surgical birth. Adequate hydration, rest, emotional and physical support, and, if needed, pharmacologic sedation can be encouraged as alternatives to early hospital admission. Patience should be the critical factor here.

Amniofusion

this is warm sterile normal saline or lactated ringers injected into the uterus through the cervix * Indications * Severe variable decelerations due to cord compression * Oligohydramnios due to placental insufficiency * Postmaturity or rupture of membranes * Preterm labor with premature rupture of membranes * Thick meconium fluid * Nursing management: teaching, maternal and fetal assessment, preparation for possible cesarean birth * 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.

Forceps and vacuum assisted birth

* Application of traction to fetal head * Indications: prolonged second stage of labor, nonreassuring FHR pattern, failure of presenting part to fully rotate and descend, limited sensation or inability to push effectively, presumed fetal jeopardy or fetal distress, maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, infection * Risk of tissue trauma to mother and newborn * Prevention as key * Explain to woman that marks will dissapear in two to three days

Labor induction therapeutic management

* Cervical ripening (Bishop score, see Table 21.2) - bishop score of 8 or over indicates vaginal birth * Herbal agents * Castor oil, hot baths, enemas * Sexual intercourse with breast stimulation * Mechanical methods and surgical methods the risk and benefits should be explained to the woman before stimulation and know there is an increase risk for infection. -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 (King et al., 2015). * Pharmacologic agents (see Drug Guide 21.2)- Induction of labor with prostaglandins offers the advantage of promoting both cervical ripening and uterine contractility. A drawback of prostaglandins is their ability to induce excessive uterine contractions, which can increase maternal and perinatal morbidity (Callahan, 2016). Prostaglandin analogs commonly used for cervical ripening include dinoprostone gel (Prepidil), dinoprostone inserts (Cervidil), and misoprostol (Cytotec). Misoprostol (Cytotec), a synthetic PGE1 analog, is a gastric cytoprotective agent used in the treatment and prevention of peptic ulcers. It can be administered intravaginally or orally to ripen the cervix or induce labor. It is available in 100-mcg or 200-mcg tablets, but doses of 25 to 50 mcg are typically used. It is important to note that only dinoprostone is approved by the FDA for use as a cervical ripening agent, although ACOG acknowledges the apparent safety and effectiveness of misoprostol for this purpose (King et al., 2015). 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 salpingo-oophorectomy), or amniotic fluid embolism (Ahmed et al., 2015; Drug Guide 21.2). 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. * Oxytocin * A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm (Ricci 777) *

Risks for dystocia

* Epidural analgesia/excessive analgesia - keeps patient from being able to push abnormally. * Multiple gestation * Hydramnios * Maternal exhaustion * Ineffective maternal pushing technique * Occiput posterior position * Longer first stage of labor - makes a longer and difficult labor * Nulliparity, short maternal stature * Fetal birth weight over 8.8 lb * Shoulder dystocia - where shoulder gets stuck under the pelvis. * Abnormal fetal presentation or position- * Fetal anomalies * Maternal age over 35 years * High caffeine intake * Overweight * Gestational age over 41 weeks * Chorioamnionitis * Ineffective uterine contractions * High fetal station at complete cervical dilation - baby hasnt dropped down but fully dilated when this happens a procedure called laboring down is done where contractions push the baby down.

Labor Induction and Augmentation

* Induction: stimulating contractions via medical or surgical means - can be done in cases of fetal demise * Augmentation: enhancing ineffective contractions after labor has begun * Indications: prolonged gestation, prolonged premature rupture of the membranes, gestational hypertension, cardiac disease, renal disease, chorioamnionitis, dystocia, intrauterine fetal demise, isoimmunization, and diabetes * Cephaloperlvuc disproportions should be ruled out in order to do labor inductions * Only should be performed for a clear medical reason * 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 fetal heart rate pattern; complete blood count and urinalysis to rule out infection; and a vaginal examination to evaluate the cervix for inducibility (Kriebs, 2015). Accurate dating of the pregnancy also is essential before cervical ripening and induction are initiated to prevent a preterm birth.

Labor induction assessment and management

* Nursing assessment * Relative indications; gestational age determination * Fetal status; maternal status; Bishop score * Nursing management * See Nursing Care Plan 21.1 * Explanations (see Teaching Guidelines 21.2) * Oxytocin administration * Pain relief and support

Post term labor assessment and management

* Nursing assessment: estimated date of birth; daily fetal movement counts, nonstress tests twice weekly, amniotic fluid analysis, weekly cervical examinations, client understanding, anxiety, and coping ability * Nursing management: fetal surveillance; decision for labor induction; support; education, intrapartal care * 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 (Soni, Vaishnav, & Gohil, 2015). Encourage the woman to verbalize her feelings and concerns, and answer all her questions. Provide support, presence, information, and encouragement throughout this time.

Amniotic fluid embolisms

* Obstetric emergency * Sudden onset of hypotension, hypoxia, and coagulopathy due to breakage in barrier between maternal circulation and amniotic fluid it is vital that there is a quick diagnosis * Nursing assessment: difficulty breathing, hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony with subsequent hemorrhage, ARDS, cardiac arrest * Nursing management: supportive measures to maintain oxygenation and hemodynamic function and to correct coagulopathy; critical care monitoring care is supportive these patients are going to the unit. * 100 percent oxygen is used in these situations

Cord prolapse

* Obstetric emergency - * baby deteriorates rapidly from a decrease in perfusion. * sudden fetal bradycardia is one of the first signs of umbilical cord prolapse * do not force the cord back in instead put on a sterile glove and hold the presenting part off the cord patient needs to be in modified sims and mom needs oxygen. * Call for help immediately make this the first action and do not leave wonan * Pathophysiology: partial or total occlusion of cord with rapid fetal deterioration * Nursing assessment * Prevention; risk factors * Continuous assessment of client and fetus * Often first signs are fetal bradycardia and variable decelerations * * Nursing management * Prompt recognition * Measures to relieve compression * 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 fetal heart rate, 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. (Ricci 787) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Uterine rupture

* Obstetric emergency; onset marked by sudden fetal bradycardia * Nursing assessment * Risk factors- 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 (Nahum & Pham, 2015). Reviewing a client's history for risk factors might prove to be lifesaving for both mother and fetus. (Ricci 788) * Onset of sudden fetal distress; other signs * Nursing management * Preparation for urgent cesarean birth * Continuous maternal and fetal monitoring * Requirers cesarean birth * Insert Foley catheter

Post term labor

* Pregnancy continuing past end of 42 weeks' gestation * Unknown etiology * Maternal risks: cesarean birth, dystocia, birth trauma, postpartum hemorrhage, and infection. * Fetal risks: macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, and cephalopelvic disproportion * Occurs in 7% of all pregnancies * Woman who had one post term labor is at greater risk for another * Fetal risks associated with a post-term 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. The perinatal mortality rate at more than 42 weeks of gestation is twice that at term and increases sixfold and higher at 43 weeks of gestation and beyond. Uteroplacental insufficiency, meconium aspiration, and intrauterine infection contribute to the increased rate of perinatal deaths (Callahan, 2016). 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 (Caughey & Butler, 2015). All of these issues can compromise fetal well-being and lead to fetal distress. (Ricci 775)

Dystocia causes psyche

* Problems with psyche * Psychological distress - fear and anxiety stimulate the release of stress hormones and stress hormones lead to myeometrial dysfunctions epinepherine and norepinephrine cause contractions.

Preterm labor

* Regular uterine contractions with cervical effacement and dilation between 20 and 37 weeks' gestation * About 12% of births in us are preterm labors * The rate of preterm births in the United States has increased 35% in the past 20 years. Preterm births account for 75% of neurodevelopmental disorders and other serious morbidities, as well as behavioral and social problems. They account for 85% of all perinatal morbidity and mortality. In addition, up to $30 billion is spent on maternal and infant care related to prematurity * Infants born prematurely also are at risk for serious sequelae such as respiratory distress syndrome, infections, congenital heart defects, thermoregulation problems that can lead to acidosis and weight loss, intraventricular hemorrhage, jaundice, hypoglycemia, feeding difficulties resulting from diminished stomach capacity and an underdeveloped suck reflex, and neurologic disorders related to hypoxia and trauma at birth. Many will face the prospect of numerous lifelong disabilities, such as cerebral palsy, intellectual impairment, vision defects, and hearing loss. A recent study's findings indicated that a single course of corticosteroids prenatally improved most neonate's * Although great strides have been made in neonatal intensive care, prematurity remains the leading cause of death within the first month of life and is the second leading cause of all infant deaths (March of Dimes, 2015b). The exact cause of preterm labor is not known. Currently, prevention is the goal. (Ricci 769) * One of most common obstetric complications * Therapeutic management * Risk prediction * Tocolytic drugs: there are no clear first-line drugs to manage preterm labor; may prolong pregnancy for 2 to 7 days while steroids can be given for fetal lung maturity one of the goals of tocolytic is to keep baby in gestation until lungs mature. * abruptio placenta acute fetal distress, active vaginal bleeding, cervical dilation greater than 6cm * Antibiotic prophylaxis for women with group B streptococcus - start dose of antibiotics if woman has not been tested * Risk factors (see Box 21.2) * Subtle signs (see Teaching Guidelines 21.1) * Contraction pattern (4 contractions every 20 minutes or 8 contractions in 1 hour) - points to preterm labor * Laboratory and diagnostic testing: CBC, urinalysis, amniotic fluid analysis, fetal fibronectin- predictor of impending rupture of membranes is the glue that holds the fetal sac and the uterine lining together if leeching greater than 0.05 mcg ml indicates impending labor , cervical length via transvaginal ultrasound, salivary estriol, home uterine activity monitoring * Tocolytic administration (See Drug Guide 21.1 and Evidence-Based Practice 21.1) * Client education * Psychological support * A single course of corticosteroids is recommended for all pregnant women between 24 and 34 weeks of gestation who are at risk of preterm birth within 7 days. Prenatal corticosteroids significantly reduce the incidence and severity of neonatal respiratory distress syndrome. (Ricci 769) * Tocolytic drugs may prolong pregnancy for 2 to 7 days; during this time, steroids can be given to improve fetal lung maturity and the woman can be transported to a tertiary care center. (Ricci) * 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

Preterm labor nursing management

* Tocolytic administration (See Drug Guide 21.1 and Evidence-Based Practice 21.1) * tocolytics -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) (see Evidence-Based Practice 21.1). These drugs are used "off label," which means that they are effective for this purpose but have not been officially tested and developed for this purpose by the U.S. Food and Drug administration (FDA) (Haas et al., 2014). In a recent Cochrane review study, calcium channel blockers were found to be better in preventing preterm labor when compared to beta-mimetics (Flenady et al., 2014). All of these medications have serious side effects, and the woman needs close supervision when they are being administered * 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 of gestation. The beneficial effects of corticosteroids on fetal lung maturation have been reported within 48 hours of initial administration. A recent Cochrane review found that corticosteroids repeatedly administered to the woman in preterm labor provided short-term benefits to the preterm infant of less respiratory distress and fewer serious health problems in the first few weeks after birth. 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. The current available evidence reassuringly shows no significant harm in early childhood, although no benefit. Further research is needed on the long-term benefits and risks for the woman and baby. Individual client data meta-analysis may clarify how to maximize benefit and minimize harm (Cabbad et al., 2015). These drugs require at least 24 hours to become effective, so timely administration is crucial. * * and bedrest * Client education * teach clients about signs between true and false labor. * Psychological support * Assessment of preterm labor * - Change or increase in vaginal discharge with mucous, 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 (Jordan et al., 2014). * Assess the pattern of the contractions: the contractions must be persistent, such that four contractions occur every 20 minutes or 8 contractions occur in 1 hour. Evaluate cervical dilation and effacement: cervical effacement is 80% or greater and cervical dilation is greater than 1 cm (ACOG, 2014b). On examination, engagement of the fetal presenting part will be noted. (Ricci 772) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Dystocia Assessment and Management

VBAC - a vaginal birth after ceassection * Nursing assessment * History of risk factors * Maternal frame of mind * Vital signs- look for signs of maternal distress. * Uterine contractions * Fetal heart rate, fetal position - asses babies fetal heart rate and position * Leopolds maneuver to determine fetal position * Report any malodorous fluid note any rise in temperature * Nursing management (see Table 21.1) * Promoting labor progress - check for dilation and effacement, look at the babies station use the rule of one cm per hour for dilation if membranes have ruptured check for signs of visible cord prolapse also if fetus is in breech position be sure to check for visible cord prolapse , check the fluid status and check for bladder dissension every two hours check bowel patterns as well and remember that full bowel and bladder can impede descent. Continuously monitor fetal heart rate status be ready to administer oxytocin in case of hypotonic contraction. If shoulder dystocia be ready to manipulate baby and prepare for cessarian if labor does not progress * Providing physical and emotional comfort - promote relaxation and relieve stress respect wishes as far as pain relief is concerned. Examples are massages blankets and other techniques change the woman's position every 30 minutes upright positions are the most helpful. Provide counter pressure and back rubs for the posterior occipitus positions, administer analgesics as ordered d * Promoting empowerment - give all information and make them feel that they are capable of deciding how their labor should progress after they have been educated. * Requires patience dystocia is associated diagnosed after labor and not before