chapter 21

ACOG guidelines for ABAC

The ACOG (2010) guidelines state that VBACs are safe and appropriate for most women, but emphasize the need for thorough counseling, shared decision making, and client autonomy. Nurses must act as advocates, giving input on the appropriate selection of women who wish to undergo VBAC. Nurses also need to become experts at reading fetal monitoring tracings to identify fetal distress and set in motion an emergency birth. Including all of these nursing strategies will make VBAC safer for all.

period following fetal death

The period following a fetal death is extremely difficult for the family. For many women, emotional healing takes much longer than physical healing. The feelings of loss can be intense. The grief response in some women may be so great that their relationships become strained, and healing can become hampered unless appropriate interventions and support are provided.

administering tocolytic therapy

use of drugs to inhibit uterine contractions.

Indomethacin [Indocin] actions

Inhibits prostaglandins, which stimulate contractions; inhibits uterine activity to arrest preterm labor

nursing mgmt of placenta previa

Nursing management within the acute care setting includes the following: 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

risks for persistent breech presentations

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

evaluate cervical dilation and affacement

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.

when prolapse is more likely to occur

When the presenting part does not fully occupy the pelvic inlet, prolapse is more likely to occur.

ADR of oxytocin

he 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.

labor induction

involves the stimulation of uterine contractions by medical or surgical means before the onset of spontaneous labor. The labor induction rate is at an all-time high in the United States. The widespread use of artificial induction of labor for convenience has contributed to the recent increase in the number of cesarean births.

LGBTQ individuals

not a homogenous group and they are shaped by a range of factors including race, sexual orientation, ethnicity, socioeconomic status, and age.

postterm pregnancy

A postterm or prolonged pregnancy is defined as a pregnancy that extends to 42 0/7 weeks and beyond.

vacuum extractor

A vacuum extractor is a cup-shaped instrument attached to a suction pump used for extraction of the fetal head (Fig. 21.7). 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

aminotic fluid embolism

AFE is an unforeseeable, life-threatening complication of childbirth. AFE remains an enigmatic, but devastating obstetric condition associated with significant maternal and newborn morbidity and mortality. It is a rare and often fatal event characterized by the sudden onset of hypotension, hypoxia, and coagulopathy. 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 (Sadera & Vasudevan, 2015). Prediction and diagnosis of the event are nearly impossible. However, timely recognition and response is critical in saving a woman's life. Although estimates vary, AFE, also referred to as anaphylactoid syndrome of pregnancy, occurs in 1 in 15,000 births, with a reported mortality rate reaching 60% despite technologic advances in critical care life support

contrindications to administering tocolytic agents

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

c/s

A cesarean birth is the surgical birth of the fetus through an incision in the abdomen and uterine wall and is the most commonly performed surgery in the United States (Green, 2016). A classic (vertical) or low transverse (horizontal) incision may be used; however, the low transverse incision is more common today

c/s for placental abruption

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.

aminioinfusion

Amnioinfusion is 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. Studies support the use of this procedure a safe and effective in resolving FHR decelerations

pathophys of AFE

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. This condition has a high mortality rate: as many as 50% of women die within the first hour after the onset of symptoms, and about 85% of survivors have permanent hypoxia-induced neurologic damage

umbilical cord prolapse

An umbilical cord prolapse is the protrusion of the umbilical cord alongside (occult) or ahead of the presenting part of the fetus (Fig. 21.5). This condition occurs in 1 out of every 300 births and requires prompt recognition and intervention for a positive outcome (March of Dimes, 2015c). Cord prolapse occurs in 3% of deliveries when the fetus is in the vertex position and in 3.7% of deliveries when the fetus is in the breech position. The risk is increased further when the presenting part does not fill the lower uterine segment, as is the case with incomplete breech presentations (5% to 10%), premature infants, and multiparous women (Bush, Eddleman, & Belogolovkin, 2015). With a 50% perinatal mortality rate, it is one of the most catastrophic events in the intrapartum period

post-op care c/s

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.

risks from c/s

Cesarean birth is a major surgical procedure with increased risks compared with a vaginal birth. 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

reason for c/s

Cesarean births may result from maternal, fetal, or placental factors that interfere with a vaginal birth. Several factors may explain this increased incidence of cesarean deliveries: the use of electronic fetal monitoring, which identifies fetal distress early; the reduced number of forceps-assisted births; older maternal age and reduced parity; increasing maternal obesity, with more nulliparous women having infants; convenience to the client and doctor; and an increase in malpractice suits. The leading indications for cesarean births are previous cesarean birth, breech presentation, dystocia, and fetal distress. 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

caring for the women who is receiving an aminoinfusion, including 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.

forceps or vacuum-assisted birth

Forceps or a vacuum extractor may be used to apply traction to the fetal head or to provide a method of rotating the fetal head during birth

maternal s/sx of placenta previa

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.

maternal trauma from forceps or vacuum

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 (Cunningham et al., 2014). 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.

nsg mgmt for UCP

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. Inform the woman of what is happening and what options may be discussed by her health care provider. 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.

most common indications for primary c-section

One in three women who gives birth in the United States today does so by a cesarean birth. The most common indications for primary cesarean births include, in order of frequency, labor dystocia, abnormal fetal heart rate (FHR) tracing, fetal malpresentation, multiple gestation, and suspected macrosomia.

placenta previa

Placenta previa is 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 Reported incidence is approximately 1 in 200 birth direct relationship between the number of previous cesarean births and the risk of placenta previa, probably due to uterine scarring. The degree of occlusion of the internal cervical os may depend on the degree of cervical dilation, so what may appear to be a low-lying or marginal placenta previa prior to the onset of labor can progress to become more serious as the cervix effaces and opens up

placenta abruption

Placental abruption refers to premature separation of a normally implanted placenta from the maternal myometrium 1% of all preg

maternal complications of shoulder dystocia

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

RF for AFE

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. However, many women present without any of the risk factors.

preop for c/s

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.

prevention for using forceps/vacuum

Prevention is key to reducing the use of these techniques. 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

Betamethasone [celestone] Actions

Promotes fetal lung maturity by stimulating surfactant production; prevents or reduces risk of respiratory distress syndrome and intraventricular hemorrhage in the preterm neonate less than 34 wks' gestation

c/s anesthesia

Spinal, epidural, or general anesthesia is used for cesarean births.

clinical appearance for AFE

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

therapuetic mgmt 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;

RF for placenta previa

The incidence of maternal mortality is less than 1%, but common morbidities include septicemia, renal failure, hemorrhage and hypovolemic shock, invasive placenta (accrete, increta, and percreta), and postpartum anemia. Risk factors for placenta previa include previous cesarean section, advanced maternal age >34, multiparity, multiple gestation, prior placenta previa, and cigarette smoking. The risk for perinatal mortality is less than 10%, but common neonatal morbidities include stillbirth, prematurity, malpresentation, fetal growth restriction, and fetal anemia

indications for forceps or vacuum

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.

complications of multifetal

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.

overall materal prognosis of placenta previa

The overall maternal prognosis is good if hemorrhage is controlled and sepsis or other complications are prevented. Fetal prognosis is directly related to the amount of blood loss. The United States perinatal mortality rate associated with placental previa is 2% to 3%, and the maternal mortality rate is 0.03%. Risk for placenta previa recurrence in subsequent pregnancies is 4% to 8%

reason for aminioinfusion

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. However, it does not prevent meconium aspiration syndrome (Hofmeyr, Xu, & Eke, 2014). Contraindications to amnioinfusion include vaginal bleeding of unknown origin, umbilical cord prolapse, amnionitis, uterine hypertonicity, and severe fetal distress

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 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

uterine rupture

Uterine rupture in pregnancy is a rare and often catastrophic complication with a high incidence of fetal and maternal morbidity. Uterine rupture is 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.

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

post op monitoring for placenta previa

closely monitor postsurgically for bleeding, infection, and other complications; assess client's anxiety level and coping ability; and provide emotional support and reassurance.

arrest disroders

complete cession of labor progress

factors associated with increased risk 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, and high fetal station at complete cervical dilation.

nursing assessment uterine rupture

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 Screening all women with previous uterine surgical scars is important, and continuous electronic fetal monitoring should be used during labor because this may provide the only indication of an impending rupture.

contrindications to VBAC

nclude 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

RF for placenta abruption

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

mgmt of placenta previa

prompt treatment with bed rest, close monitoring, and control/replacement of blood loss greatly reduces risk for maternal and fetal complications and death.

persistent occiput posterior

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.

reasons for longer labors

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

problems with the passengers

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. These variations can affect the contractions or fetal descent through the maternal pelvis. Common problems involving the fetus include occiput posterior position, breech presentation, multifetal pregnancy, excessive size (macrosomia) as it relates to cephalopelvic disproportion, and structural anomalies.

birth plan for twins

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' gestation. As long as the presenting twin is vertex, a vaginal birth should be considered

dystocia

abnormal or difficult labor

breech presentation can indicate

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.

asses the pattern of contractions

the contractions must be persistent, such that four contractions occur every 20 minutes or eight contractions occur in 1 hour.

risks of preterm birth

uch 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

Nifidipine [Procardia]

Blocks calcium movement into muscle cells, inhibits uterine activity to arrest preterm labor

abnormalities or problems resulting in dystoscia

expulsive forces (known as the "powers"); presentation, position, and fetal development (the "passenger"); the maternal bony pelvis or birth canal (the "passageway"); and maternal stress (the "psyche").

problems with the psyche

may include fear, anxiety, helplessness, isolation, and weariness

teaching to prevention preterm labor

-Avoid traveling for long distances in cars, trains, planes, or buses. -Avoid lifting heavy objects, such as laundry, groceries, or a young child. -Avoid performing hard, physical work, such as yard work, moving of furniture, or construction. -Mild to moderate levels of exercise are permitted such as walking daily. -Achieve an appropriate prepregnancy weight. -Achieve adequate iron stores through balanced nutrition. -Wait at least 18 months between pregnancies. -Visit a dentist in early pregnancy to evaluate and treat periodontal disease. -Enroll in a smoking cessation program if you are unable to quit on your own. -Curtail sexual activity until after 37 weeks if experiencing preterm labor symptoms. -Consume a well-balanced nutritional diet to gain appropriate weight. -Avoid the use of substances such as marijuana, cocaine, and heroin. -Identify factors and areas of stress in your life, and use stress management techniques to reduce them. -If you are experiencing intimate partner violence, seek resources to modify the situation. Recognize the signs and symptoms of preterm labor and notify your birth attendant if any occur: Uterine contractions, cramping, or low back pain Feeling of pelvic pressure or fullness Increase in vaginal discharge Nausea, vomiting, and diarrhea Leaking of fluid from vagina If you are experiencing any of these signs or symptoms, do the following: Stop what you are doing and rest for 1 hour. Empty your bladder. Lie down on your side. Drink two to three glasses of water. Feel your abdomen and make note of the hardness of the contraction. Call your health care provider and describe the contraction as: Mild if it feels like the tip of the nose Moderate if it feels like the tip of the chin Strong if it feels like your forehead

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

grief accompanying the loss of a fetus in the following order

1. Accepting the reality of the loss 2. Getting over suffering from the loss 3. Adapting to the new environment without the deceased Emotionally relocating the deceased and getting on with life

corticosteroid use for preterm babies

A recent study's findings indicated that a single course of corticosteroids prenatally improved most neonate's neurodevelopmental outcomes if given before 34 weeks' gestation 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. these drugs require at least 24 hours to become effective, so timely administration is crucial

risk factors for breech presentation

3% to 4% of cases, however, the fetus will remain in a breech presentation with the buttocks or feet presenting. There is less risk to the fetus and mother when the head is down at the time of birth. 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

Mgso4 nsg implications

Administer IV with a loading dose of 4-6 g over 15-30 min initially, and then maintain infusion at 1-4 g/hr. Assess vital signs and deep tendon reflexes (DTRs) hourly; report any hypotension or depressed or absent DTRs. Monitor level of consciousness; report any headache, blurred vision, dizziness, or altered level of consciousness. Perform continuous electronic fetal monitoring; report any decreased FHR variability, hypotonia, or respiratory depression. Monitor intake and output hourly; report any decrease in output (<30 mL/hr). Assess respiratory rate; report respiratory rate <12 breaths/min; auscultate lung sounds for evidence of pulmonary edema. Monitor for common maternal side effects, including flushing, nausea and vomiting, dry mouth, lethargy, blurred vision, and headache. Assess for nausea, vomiting, transient hypotension, lethargy. Assess for signs and symptoms of magnesium toxicity, such as decreased level of consciousness, depressed respirations and DTRs, slurred speech, weakness, and respiratory and/or cardiac arrest. Have calcium gluconate readily available at the bedside to reverse magnesium toxicity.

Betaethasone [Celestone] nsg implications

Administer two doses intramuscularly 24 hr apart. Monitor for maternal infection or pulmonary edema. Educate parents about potential benefits of drug to preterm infant. Assess maternal lung sounds and monitor for signs of infection.

risk of admitting women too early

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.

risk factors associated with preterm labor and birth

African-American race (double the risk) Maternal age extremes (<16 years and >40 years old) Low socioeconomic status Alcohol or other drug use, especially cocaine Poor maternal nutrition Maternal periodontal disease Cigarette smoking Low level of education History of prior preterm birth (triples the risk) Uterine abnormalities, such as fibroids Low pregnancy weight for height Pre-existing diabetes or hypertension Multiple pregnancy Premature rupture of membranes Late or no prenatal care Short cervical length Sexually transmitted infections: gonorrhea, Chlamydia, trichomoniasis Bacterial vaginosis (50% increased risk) Chorioamnionitis Hydramnios Gestational hypertension Cervical insufficiency Short interpregnancy interval (<1 year between births) Placental problems, such as placenta previa and abruption placenta Maternal anemia Urinary tract infection Domestic violence Stress, acute and chronic

hypertonic uterine dysfunction

occurs when the uterus never fully relaxes bw contractions 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

morbidity of prematurity

prematurity remains the leading cause of death within the first month of life and is the second leading cause of all infant deaths

goals of tocolytic therapy

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.

early pregnancy loss

Early pregnancy loss may be through a spontaneous abortion (miscarriage), an induced abortion (therapeutic abortion), or a ruptured ectopic pregnancy.

steps for administering oxytocin

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.

nursing assessment

Begin the assessment by reviewing 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 (Green, 2016). Include in the assessment the mother's frame of mind to identify fear, anxiety, stress, lack of support, and pain, which can interfere with uterine contractions and impede labor progress. Helping the woman to relax will promote normal labor progress. 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 maneuvers (see Chapter 14 for more information) to 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.

cervical ripening

Cervical ripening is a process by which the cervix softens via the breakdown of collagen fibrils. There has been increasing awareness that if the cervix is unfavorable or unripe, a successful vaginal birth is unlikely. 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.

lab and dx testing 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.

VBAC mgmt during prenatal

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.

Indomethacin [Indocin] nsg implications

Continuously assess vital signs, uterine activity, and FHR. Administer oral form with food to reduce GI irritation. Do not give to women with peptic ulcer disease. Schedule ultrasound to assess amniotic fluid volume and function of ductus arteriosus before initiating therapy; monitor for signs of maternal hemorrhage. Be alert for maternal adverse effects such as nausea and vomiting, heartburn, rash, prolonged bleeding time, oligohydramnios, and hypertension. Monitor for neonatal adverse effects, including constriction of ductus arteriosus, premature ductus closure, necrotizing enterocolitis, oligohydramnios, and pulmonary hypertension. Contraindicated in >32 weeks' gestations, fetal growth restriction, history of asthma, urticaria, or allergic type reactions to aspirin or NSAIDs.

There are several women in active labor on the unit. Which woman is at highest risk for developing hypotonic contractions and therefore will need frequent nursing assessments? A 21-year-old primipara woman who does not have a support person with her and is very anxious A 17-year-old primipara requesting more pain medication every 15 to 30 minutes (and not receiving it) even though there is an epidural catheter in place that is working effectively A 37-year-old G2 P1 woman being induced whose last ultrasound at 36 weeks' gestation showed oligohydramnios

Correct answer: A G4 P3 client who is having twins and wants to experience a "natural birth" Approximately half of students who answered this question in Wolters Kluwer's adaptive learning systems, powered by PrepU, answered "A 37-year-old G2 P1 woman being induced whose last ultrasound at 36 weeks' gestation showed oligohydramnios." This is not a priority for assessment among these patients. Hypotonic contractions occur during the active phase of labor and tend to occur after the administration of analgesia in a uterus that is overstretched by multiple gestation or polyhydramnios or in a uterus that is lax from grand multiparity.

providing psychological support

Every case of spontaneous preterm labor is unique. Care must take into account the clinical circumstances, and the full and informed consent of the woman and her partner is needed. Half of all women who ultimately give birth prematurely have no identifiable risk factors. Nurses should be sensitive to any complaint and should provide appropriate assessment, information, and follow-up. Sensitivity to the subtle differences between normal pregnancy sensations and the prodromal symptoms of preterm labor is a key factor in ensuring timely care. Offer validation and clarification of the woman's symptoms.

RF for IUFD

Fetal demise 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 (Hugin & Sultani, 2015). Trauma in pregnancy remains one of the major contributors to maternal and fetal morbidity and mortality. Potential complications include maternal injury or death, shock, internal hemorrhage, IUFD, direct fetal injury, abruptio placentae, and uterine rupture. The leading causes of obstetric trauma are motor vehicle accidents, falls, assaults, and gunshots, and ensuing injuries are classified as blunt abdominal trauma, pelvic fractures, or penetrating trauma. In view of the significant impact of trauma on the pregnant woman and her fetus, preventive strategies are paramount

fetal risks asso with postterm

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. 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

early intervention in arresting preterm labor

Frequently, women are unaware that uterine contractions, effacement, and dilation are occurring, thus making early intervention ineffective in arresting preterm labor and preventing the birth of a premature newborn.

labor induction involves

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 (Vogel et al., 2014). Labor augmentation (stimulating the uterus, typically with oxytocin) enhances ineffective contractions after labor has begun. Continuous electronic FHR monitoring is necessary.

tocolytic drugs

Magnesium sulfate may be ordered Calcium channel blockers promote uterine relaxation by decreasing the influx of calcium ions into myometrium cells to inhibit contractions. 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

mcRoberts maneuvers

Maneuvers to relieve shoulder dystocia. A. McRoberts maneuver. The mother's thighs are flexed and abducted as much as possible to straighten the pelvic curve. B. Suprapubic pressure. Light pressure is applied just above the pubic bone, pushing the fetal anterior shoulder downward to displace it from above the mother's symphysis pubis. The newborn's head is depressed toward the mother's anus while light suprapubic pressure is applied.

mechanial methods of cervical ripening

Mechanical methods are used to open the cervix and stimulate the progression of labor. Potential advantages of mechanical methods, compared with pharmacologic methods, may include simplicity or preservation of the cervical tissue or structure, lower cost, and fewer side effects. The risks associated with these methods include infection, bleeding, membrane rupture, and placental disruption. For example, an indwelling (Foley) catheter 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). Hygroscopic dilators are advantageous because they can be inserted on an outpatient basis and no fetal monitoring is needed.

nonpharm methods for cervical ripening

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

normal labor

Normal labor starts with regular uterine contractions that are strong enough to result in cervical effacement and dilation

caring for LGBTQ clients

Nurses caring for LGBTQ clients need to allow them to have their own identity, values, and beliefs. Every client should be treated with the kindness, with an individualized approach and be an advocate for their needs. Nurses need to consider the following when they are caring for the childbearing LGBTQ family by using appropriate language/identification and cultural representation by asking how they wish to be identified; and by personalizing their care that includes all intersecting aspects of their identity

advantages of oxytocin

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

Oxytocin administration

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. 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 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

maternal risk of postterm

Postterm pregnancies may adversely affect both the mother and fetus or newborn. 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. Women often blame themselves for prolonging the pregnancy, and a woman's negative feelings about herself can bring about strained relationships with the people closest to her.

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. The female pelvis can be classified into four types based on the shape of the pelvic inlet, which is bounded anteriorly by the posterior border of the symphysis pubis, posteriorly by the sacral promontory, and laterally by the linea terminalis. The four basic types are gynecoid, anthropoid, android, and platypelloid (see Chapter 12 for additional information). 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.

Management of shoulder 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

pharm methods of cervical ripening

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 salpingooophorectomy), or amniotic fluid embolism (AFE) (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 (VBAC).

to assist familyies in the grieving process, include the following:

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.

MgSO4 actons

Relaxes uterine muscles to stop irritability and contractions, to arrest uterine contractions for preterm labor (off-label use). Has been used in seizure prophylaxis and treatment of seizures in preeclamptic and eclamptic clients for almost 100 yrs

shoulder dystocia

obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. OB emergency no reliable way to predict fetus at risk for injury

sx methods of cervical ripening

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. Manual separation of the amniotic membranes from the cervix is thought to induce cervical ripening and the onset of labor (Afzal, Asif, & Miraj, 2015). However, there is no strong evidence at this time that membrane stripping significantly shortens the duration of pregnancy. 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

bishop score

The Bishop score helps identify women who would be most likely to achieve a successful induction (Table 21.2). The duration of labor is inversely correlated with the Bishop score: a score over 8 indicates a successful vaginal birth. Bishop scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction

etiology of postterm pregnancy

The exact etiology of a postterm or prolonged pregnancy is unknown because the mechanism for the initiation of labor is not completely understood. Theories suggest there may be a deficiency of estrogen and continued secretion of progesterone that prohibits the uterus from contracting,

major risk with hypotonic uterine dysfunction

The major risk with this complication is hemorrhage after giving birth because the uterus cannot contract effectively to compress blood vessels.

Many factors influence the decision to intervene when women present with symptoms of preterm labor, including the probability of progressive labor, gestational age, and the risks of treatment. ACOG (2014b) recommends the following as guidelines:

There are no clear first-line tocolytic drugs (drugs that promote uterine relaxation by interfering with uterine contractions) to manage preterm labor, and the results of research on their efficacy are mixed. Clinical circumstances and the health care provider's preference should dictate treatment. Antibiotics do not appear to prolong gestation and should be reserved for group B streptococcal prophylaxis in women in whom birth is imminent. 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. 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.

failure to progress

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.

multiple or multifetal gestation

Twins, triplets, or more infants within a single pregnancy

Nifedipine [Procardia] nsg implications

Use caution if giving this drug with magnesium sulfate because of increased risk for hypotension. Monitor blood pressure hourly if giving with magnesium sulfate; report a pulse rate >110 bpm. Monitor for fetal effects such as decreased uteroplacental blood flow manifested by fetal bradycardia, which can lead to fetal hypoxia. Monitor for adverse effects, such as flushing of the skin, headache, transient tachycardia, palpitations, postural hypertension, peripheral edema, and transient fetal tachycardia. Contraindicated in women with cardiovascular disease or hemodynamic instability.

teaching in prep for labor induction

Your health care provider may recommend that you have your labor induced. This may be necessary for a variety of reasons, such as elevated blood pressure, a medical condition, prolonged pregnancy over 41 weeks, or problems with fetal heart rate patterns or fetal growth. Your health care provider may use one or more methods to induce labor, such as stripping the membranes, breaking the amniotic sac to release the fluid, administering medication close to or in the cervix to soften it, or administering a medication called oxytocin (Pitocin) to stimulate contractions. Labor induction is associated with some risks and disadvantages, such as overactivity of the uterus; nausea, vomiting, or diarrhea; and changes in fetal heart rate. Prior to inducing your labor, your health care provider may perform a procedure to ripen your cervix to help ensure a successful induction. Medication may be placed around your cervix the day before you are scheduled to be induced. During the induction, your contractions may feel stronger than normal. However, the length of your labor may be reduced with induction. Medications for pain relief and comfort measures will be readily available. Health care staff will be present throughout labor.

anencephaly

fetal abN asso with face and brow presentations

precipitate labor

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 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 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

nursing management

ursing management of the woman with dystocia, regardless of the etiology, requires patience. The nurse should provide physical and emotional support to the client and her family. The final outcome of any labor depends on the size and shape of the maternal pelvis, the quality of the uterine contractions, and the size, presentation, and posi

Oxytocin

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.

problems with the powers

uterus may either never fully relax (hypertonic contractions), placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions.

occurrence of dystocia

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

box 21.1: multiple pregnancy

As the name implies, a multiple pregnancy or a multifetal pregnancy involves more than one fetus. These fetuses can result from fertilization of a single ovum or multiple ova. Monozygotic (identical) twins develop from one single ovum that divides into equal halves during early cleavage phase. Monozygotic twins are genetically identical; always the same gender, and look very similar in appearance. The number of amnions and chorions depends on the timing of division (cleavage). One fertilized ovum splitting into two separate individuals is termed natural clones. This type of twinning occurs in approximately 1 of 250 live births (March of Dimes, 2015a). Twin pregnancies that are multiple-ova conceptions (dizygotic twins) result from two ova fertilized by two sperm. They are referred to as fraternal twins. Genetically, dizygotic twins are as alike (or unlike) as any other pair or siblings. There are separate amnions and chorions although the chorions and placentas may be fused. The incidence of dizygotic twinning is approximately 1 in 500 Asians, 1 in 125 Whites, and as high as 1 in 20 in African populations (March of Dimes, 2015a). Fraternal twins account for two thirds of all twins and there is a tendency to repeat within families. Currently the incidence of fraternal twins is increasing secondary to advancing maternal age when pregnancy occurs and an increase in use of fertility drugs and procedures being done. Multiple births other than twins can be of the identical type, the fraternal type, or combinations of the two. Triplets can occur from the division of one zygote into two, with one dividing again, producing identical triplets, or they can come from two zygotes, one dividing into a set of identical twins, and the second zygote developing as a single fraternal sibling, or from three separate zygotes. Triplets are said to occur once in 7,000 births and quadruplets once in 660,000 births. In recent years, fertility drugs used to induce ovulation have resulted in a greater frequency of quadruplets, quintuplets, sextuplets, and even octuplets.

providing care during the intrapartum period

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

tocolytic therapy

The decision to stop preterm labor is individualized based on risk factors, extent of cervical dilation, membrane status, fetal gestational age, and presence or absence of infection. 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

intrauterine fetal demise

When an unborn life suddenly ends with fetal loss, the family members are profoundly affected. IUFD is fetal death that occurs after 20 weeks' gestation but before birth. The cause of IUFD is often unknown. The sudden loss of an expected child is tragic and the family's grief can be very intense: it can last for years and can cause extreme psychological stress and emotional problems

advise for women with a breech presentation

Women with a breech presentation today are often advised to have a surgical birth with no attempt to rotate the fetal position

fetal fibronectin

acts as biologic glue, attaching the fetal sac to the uterine lining 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 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.

incidence of multifetal

incidence is increasing, primarily as a result of infertility treatment (both ovarian stimulation and in vitro fertilization) and an increased number of women giving birth at older ages. The incidence of twins, triples, and higher-order multiple gestations have now reached approximately 3% of all pregnancies. The incidence of twins is approximately 1 in 30 conceptions, with about two thirds of them due to the fertilization of two ova (dizygotic or fraternal) and about one third occurring from the splitting of one fertilized ovum (monozygotic or identical twins). One in approximately 8,100 pregnancies results in triplets

medications commonly used for tocolysis

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).

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

medical and obstetric reasons for inducing labor

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 (Jordan et al., 2014). 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

marcosomia

newborn weighs 4,000 to 4,500 g (8.81 to 9.92 lb) or more at birth Associated with later life obesity, diabetes, and cardiovascular disease

preterm labor

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. Preterm births remain one of the biggest contributors to perinatal morbidity and mortality in the world. According to the March of Dimes (2015b), about 12% of births (one in eight infants) in the United States are premature.