Ch. 21 ob

Labor Augmentation

• enhances ineffective contractions after labor has begun. • Continuous electronic FHR monitoring is necessary.

Teaching to prevent 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. • 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 1. Mild if it feels like the tip of the nose 2. Moderate if it feels like the tip of the chin 3. Strong if it feels like your forehead

Corticosteroids

• 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.

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). • It describes a labor lasting more than 18 to 24 hours. • Diagnostic criteria are 1.2 cm per hour for primips and 1.5 cm per hour for multips. For protracted descent, the criteria are less than 1.0 cm per hour in primips and less than 2.0 cm per hour for multips

Pitocin Nursing Implications

• Administer as an IV infusion via pump, increasing dose based on protocol until adequate labor progress is achieved. • Assess baseline vital signs and FHR and then frequently after initiating oxytocin infusion. • Determine frequency, duration, and strength of contractions frequently. • Notify health care provider of any uterine hypertonicity or abnormal FHR patterns. • Maintain careful I&O, being alert for water intoxication. • Keep client informed of labor progress. • Monitor for possible adverse effects such as hyperstimulation of the uterus, impaired uterine blood flow leading to fetal hypoxia, rapid labor leading to cervical lacerations or uterine rupture, water intoxication (if oxytocin is given in electrolyte-free solution or at a rate exceeding 20 mU/min), and hypotension.

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 • Preexisting diabetes or hypertension • Multifetal pregnancy • Premature rupture of membranes • Late or no prenatal care • Short cervical length • STIs: 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 • UTI • Domestic violence • Stress, acute and chronic

Nursing assessment for prolonged pregnancy

• Antepartum assessment typically includes daily fetal movement counts done by the woman, nonstress tests done twice weekly, amniotic fluid assessments as part of the biophysical profile, and weekly cervical examinations to evaluate for ripening.

Problems with the Passenger

• Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia. • Common problems involving the fetus include occiput posterior position, breech presentation, multifetal pregnancy, excessive size (macrosomia) as it relates to CPD, and structural anomalies.

Health History and Physical Examination for preterm labor

• Ask the woman about any complaints, being alert for the subtle symptoms of preterm labor, which may include: - Change or increase in vaginal discharge with mucous, water, or blood in it - Pelvic pressure (pushing-down sensation) - Low, dull backache - Menstrual-like cramps - Feeling of pelvic pressure or fullness - GI upset: nausea, vomiting, and diarrhea - General sense of discomfort or unease - Heaviness or aching in the thighs - Uterine contractions, with or without pain - More than six contractions per hour - Intestinal cramping, with or without diarrhea • Assess the pattern of the contractions: the contractions must be persistent, such that four contractions occur every 20 minutes or eight contractions occur in 1 hour. • Evaluate cervical dilation and effacement: cervical effacement is 80% or greater and cervical dilation is greater than 1 cm

Nursing Assessment for preterm labor

• Because the etiology is often multifactorial, an individualized approach is needed.

Nursing Assessment for dystocia

• Begin the assessment by reviewing the client's history to look for risk factors for dystocia • 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 fetal heart rate (FHR) and pattern, reporting any abnormal patterns immediately. • Assess fetal position via Leopold's maneuvers 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.

Laboratory and Diagnostic 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 (UTI); and an amniotic fluid analysis to determine fetal lung maturity and the presence of subclinical chorioamnionitis. • Four other tests may be used for preterm labor prediction: fetal fibronectin testing, cervical length evaluation by transvaginal ultrasound, salivary estriol, and home monitoring of uterine activity to recognize preterm contractions.

Promoting the progress of Labor

• Continue to assess the woman, frequently monitoring cervical dilation and effacement, uterine contractions, and fetal descent, and document that all assessed parameters are progressing. • Evaluate progress in active labor by using the simple rule of 1 cm per hour for cervical dilation. • When the woman's membranes rupture, if they have not already ruptured, observe for visible cord prolapse. • assess the woman's fluid balance status. • Check skin turgor and mucous membranes. • Monitor intake and output. • Also monitor the client's bladder for distention at least every 2 hours and encourage her to empty her bladder often. • Continue to monitor fetal well-being.

Fetal Fibrinectin

• 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 be-tween 24 and 34 weeks of pregnancy (5½ to 8½ months) unless there has been a disruption between the chorion and deciduas. • 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. • Conversely, a negative fetal fibronectin test is a strong predictor that preterm labor in the next 2 weeks is unlikely

Forceps or Vacuum-assisted birth

• Forceps are stainless-steel instruments, similar to tongs, with rounded edges that fit around the fetus's head. Used when the fetal head is crowning and low forceps are used when the fetal head is at a +2 station or lower but not yet crowning. • vacuum extractor is a cup-shaped instrument attached to a suction pump used for extraction of the fetal head. The pump is used to create negative pressure (suction) of approximately 50 to 60 mm Hg. The birth attendant then applies traction until the fetal head emerges from the vagina. • the indications for the use of either method are similar and include a prolonged second stage of labor, a distressed FHR pattern, failure of the presenting part to fully rotate and descend in the pelvis, limited sensation and inability to push effectively due to the effects of regional anesthesia, presumed fetal jeopardy or fetal distress, maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, or infection. • The use of forceps or a vacuum extractor poses the risk of tissue trauma to the mother and the newborn. 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 • 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 ad-equate hydration throughout labor.

Problem with the Powers

• Hypertonic uterine dysfunction • Hypotonic uterine dysfunction • Protracted Disorders • Arrest disorders • Precipitate Labor

Arrest Disorders

• Include secondary arrest of dilation (no progress in cervical dilation in more than 2 hours), arrest of descent (fetal head does not descend for more than 1 hour in primip and more than 0.5 hour in multip), and failure of descent (no descent)

Cytotec nursing implications

• Instruct client about purpose and possible adverse effects of medication. • Ensure informed consent is signed per hospital policy. • Assess vital signs and FHR patterns frequently. • Monitor client's reaction to drug. • Initiate oxytocin for labor induction at least 4 hours after last dose was administered. • Monitor for possible adverse effects such as nausea and vomiting, diarrhea, uterine hyperstimulation, and category II and II FHR patterns.

Problems with the Psyche

• Intense anxiety stimulates the sympathetic nervous system, which releases catecholamines that can lead to myometrial dysfunction. Norepinephrine and epinephrine then lead to uncoordinated or increased uterine activity

Labor Induction

• Involves the stimulation of uterine contractions by medical or surgical means before the onset of spontaneous labor. • 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 • Indications for inductions include prolonged pregnancy, PPROM, gestational hypertension, cardiac disease, renal disease, chorioamnionitis, dystocia, intrauterine fetal demise, isoimmunization, and diabetes • Contraindications to labor induction include complete placenta previa, abruptio placentae, transverse fetal lie, prolapsed umbilical cord, a prior classic uterine incision that entered the uterine cavity, pelvic structure abnormality, previous myomectomy, vaginal bleeding with unknown cause, invasive cervical cancer, active genital herpes infection, and abnormal FHR patterns • *Before labor induction is started, fetal maturity (dat-ing, ultrasound, amniotic fluid studies) and cervical readiness (vaginal examination, Bishop scoring; see Table 21.2) must be assessed. Both need to be favorable for a successful induction.*

Amniotic fluid Embolism

• 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 • The clinical appearance is varied, but most women report difficulty breathing. Other symptoms include hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest • *Amniotic fluid embolism should be suspected in any pregnant women with an acute onset of dyspnea, hypotension, and DIC.* • Upon recognizing the signs and symptoms of this life-threatening diagnosis, institute supportive measures: oxygenation (resuscitation and 100% oxygen), circulation (IV fluids, inotropic agents to maintain cardiac output and blood pressure), control of hemorrhage and coagulopathy (oxytocic agents to control uterine atony and bleeding), seizure precautions, and administration of steroids to control the inflammatory response. Monitor vital signs, pulse oximetry, skin color, and temperature and observe for clinical signs of coagulopathy (vaginal bleeding, bleeding from IV site, bleeding from gums)

Nonpharmacological methods for cervical ripening

• Methods may include herbal agents such as evening primrose oil, black haw, black and blue cohosh, and red raspberry leaves, castor oil, hot baths, and enemas • sexual intercourse along with breast stimulation. This promotes the release of oxytocin, which stimulates uterine contractions. • human semen is a biologic source of prostaglandins used for cervical ripening.

Nursing Management of preterm labor

• Nursing management of the woman with preterm labor involves administering tocolytic therapy if indicated, thoroughly educating the client, and providing psychological support during the process.

Providing Physical and Emotional support

• Offer blankets for warmth and a back-rub, if the client wishes, to reduce muscle tension. • Lower the lights and reduce external noise by closing the hallway door. • Offer a warm shower to promote relaxation (if not contraindicated). • Use pillows to support the woman in a comfortable position, changing her position every 30 minutes to reduce tension and to enhance uterine activity and efficiency. • Assess the woman's level of pain and degree of distress. Administer analgesics as ordered or according to the facility's protocol.

Nursing management of prolonged pergnancy

• Once the dates have been established and postdate status is confirmed, monitoring fetal well-being becomes critical. • If the decision is to wait, then fetal surveillance is key. • If the decision is to have the woman deliver, labor induction is initiated

Pharmacological Methods for cervical ripening

• Prostaglandin analogs commonly used for cervical rip-ening include dinoprostone gel (Prepidil), dinoprostone inserts (Cervidil), and misoprostol (Cytotec) • A major adverse effect of the obstetric use of Cytotec is hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism.

Nursing management for intrauterine fetal demise

• Provide accurate, understandable information to the family. • 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. • Encourage discussion of the loss and venting of feel-ings 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.

Cervidil nursing implications

• Provide emotional support. • Administer pain medications as needed. • Frequently assess degree of effacement and dilation.Monitor uterine contractions for frequency, duration, and strength. • Assess maternal vital signs and FHR pattern frequently. • Monitor woman for possible adverse effects such as headache, nausea and vomiting, and diarrhea.

Tocolytic Drugs

• 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* • Medications most commonly used for tocolysis include magnesium sulfate (which reduces the muscle's ability to contract), terbutaline (Brethine, a beta-adrenergic), indomethacin (Indocin, a prostaglandin synthetase inhibitor), and nifedipine (Procardia, a calcium channel blocker)

Administering Tocolytic Therpay

• The primary goals of tocolytic therapy are to arrest labor and delay birth long enough to initiate prophylactic corticosteroid therapy when indicated for stimulation of fetal lung maturity and to arrange for maternal-fetal transport to a perinatal tertiary care hospital. • Diagnosis requires the presence of both uterine contractions and cervical change (or an initial cervical examination of more than 2 cm and/or more than 80% effacement in a nulliparous client). • contraindications to administering tocolytic agents to stop labor include intrauterine infection, active hemorrhage, fetal distress, fetal abnormality incompatible with life, intrauterine growth restriction (IUGR), severe preeclampsia, heart disease, prolonged premature rupture of the membranes (PPROM), and intrauterine demise

Therapeutic Management for preterm labor

• There are no clear first-line tocolytic drugs (drugs that promote uterine relaxation by interfering with uterine contractions) to manage preterm labor. 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.

Magnesium Sulfate

• 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 and is commonly used as a first-line drug.

Occiput posterior Position

• This position presents slightly larger diameters to the maternal pelvis, thus slowing fetal descent. • A fetal head that is poorly flexed may be responsible.

Transvaginal Ultrasound

• Three parameters are evaluated during the transvaginal ultrasound: cervical length and width, funnel width and length, and percentage of funneling. • 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

• 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 • Review the mother's history for risk conditions such as uterine scars, prior cesarean births, prior rupture, trauma, prior invasive molar pregnancy, history of placenta percreta or increta, congenital uterine anomalies, multiparity, previous uterine myomectomy, malpresentation, labor induction with excessive uterine stimulation, and crack cocaine use • Generally, the rst 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 • Urgent delivery by cesarean birth is usually indicated. Monitor maternal vital signs and observe for hypotension and tachycardia, which might indicate hypovolemic shock. • Insert an indwelling urinary (Foley) catheter if one is not in place already • *When excessive bleeding occurs during the childbirth process and it persists or signs such as bruising or petechiae appear, disseminated intravascular coagulation (DIC) should be suspected.*

Amniofusion

• a technique in which a volume of warmed, sterile, normal saline or Ringer's lactate solution is introduced into the uterus through an intrauterine pressure catheter to increase the volume of fluid when oligohydramnios is present. • helps to cushion the umbilical cord to prevent compression or dilute thick meconium • commonly indicated for severe variable decelerations due to cord compression, oligohydramnios due to placental insufficiency, postmaturity or rupture of membranes, preterm labor with premature rupture of membranes, and thick meconium fluid • Contraindications to am-nioinfusion include vaginal bleeding of unknown origin, umbilical cord prolapse, amnionitis, uterine hypertonicity, and severe fetal distress • Amnioinfusion should reach therapeutic result or increase the amniotic fluid volume in approximately 30 minutes

Mechanical Methods for cervical ripening

• an indwelling (Foley) catheter (e.g., 26 French) can be inserted into the endocervical canal to ripen and dilate the cervix • 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 mag-nesium sulfate (Lamicel, Dilapan). • 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

Face and Brow presentation

• are rare and are as-sociated with fetal abnormalities (anencephaly), pelvic contractures, high parity, placenta previa, hydramnios, low birth weight, or a large fetus

Problems with the Passageway

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

Providing care during the intrapartum period in prolonged pregnancy

• 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. • assess amniotic fluid characteristics (color, amount, and odor) to identify previous fetal hypoxia and prepare for prevention of meconium aspiration. • 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. • monitor the woman's labor pattern closely because dysfunctional patterns are common

Dystocia

• defined as abnormal or difficult labor, can be influenced by a vast number of maternal and fetal factors. • exist when the progress of labor deviates from normal; it is characterized by a slow and abnormal progression of labor. • It is usually during the active phase that dystocia becomes apparent. • An adequate trial of labor is needed to declare with confidence that dystocia or "failure to progress" exists. • can result from problems or abnormalities involving the 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").

Shoulder dystocia

• defined as the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. • Postpartum hemorrhage, secondary to uterine atony or vaginal lacerations, is the major complication to the mother. • Transient Erb's or Duchenne's brachial plexus palsies and clavicular or humeral fractures are the most common fetal injuries encountered • Prompt recognition and appropriate management, such as with McRobert's maneuver or suprapubic pressure, can reduce the severity of injuries to the mother and newborn • *Prompt recognition and appropriate management of shoulder dystocia can reduce the severity of injuries to the mother and infant. Immediately assess the infant for signs of trauma such as a fractured clavicle, Erb's palsy, or neonatal asphyxia. Assess the mother for excessive vaginal bleeding and blood in the urine from bladder trauma.*

Preterm Labor

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

Vaginal Birth after Cesarean (VBAC)

• describes a woman who gives birth vaginally after having at least one previous cesarean birth. • The argument against VBAC focuses on the risk of uterine rupture and hemorrhage. • Contraindications to VBAC include a prior classic uterine incision, prior transfundal uterine surgery (myomectomy), uterine scar other than low-transverse cesarean scar, contracted pelvis, and inadequate staff or facility if an emergency cesarean birth in the event of uterine rupture is required • The client must be advised about the risks as well as the benefits. • Record keeping is an important component of safe client care. • Terminal bradycardia must be considered an emergency situation, and the nurse should prepare the team for an emergency delivery. • the physician, anesthesia provider, and operating room team must be immediately available. Anything less would place the women and fetus at risk.

Risk Factors for dystocia

• epidural analgesia • excessive analgesia • multifetal pregnancy, • hydramnios • maternal exhaustion • ineffective maternal pushing technique, • occiput posterior position, • longer first stage of labor, •nulliparity, • short maternal stature (less than 5 feet tall), • fetal birth weight (more than 8.8 lb), •shoulder dystocia, • abnormal fetal presentation or position (breech), • fetal anomalies (hydrocephalus), • maternal age older than 35 years, • high caffeine intake, • overweight, • gestational age more than 41 weeks, • chorioamnionitis, • ineffective uterine contractions, and • high fetal station at complete cervical dilation.

Beta-adrenergic agonists

• expect to administer the agent as a single subcutaneous injection. • It may be repeated if the maternal heart rate remains less than 130 bpm. • Closely assess the woman for side effects, including jitteriness, flushing, hypotension, nervousness, anxiety, restlessness, nausea, and tachycardia. • Assess the fetus for tachycardia, hypotension, and hypoglycemia.

Breech presentation

• frequently associated with multifetal pregnancies, grand multiparity (more than five births), advanced maternal age, placenta previa, hydramnios, preterm births, uterine malformations or fibroids, and fetal anomalies such as hydrocephaly • Recent research has found that a planned surgical birth versus a vaginal birth does improve perinatal outcomes

Macrosomnia

• in which a newborn weighs 4,000 to 4,500 g (8.13 to 9.15 lb) or more at birth, complicates approximately 10% of all pregnancies. • 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, dysfunctional labor, fetopelvic disproportion, soft tissue laceration during vaginal birth, fetal injuries or fractures, and asphyxia

Surgical methods for cervical ripening

• 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. • An amniotomy involves inserting a cervical hook (Amniohook) through the cervical os to deliberately rupture the membranes. • Risks associated with these procedures include umbilical cord prolapse or compression, maternal or neonatal infection, FHR de-celeration, bleeding, and client discomfort

Therapeutic management of labor induction

• 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; Nitrazine paper and/or fern test to conrm ruptured membranes; complete blood count and urinalysis to rule out infection; and a vaginal examination to evaluate the cervix for inducibility

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 • 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. • Vaginal delivery is possible when bleeding is minimal, placenta previa is marginal, or labor is rapid. Pregnancy termination, early birth by cesarean section, or a hysterectomy may be necessary in order to control severe bleeding, especially for clients with complete placenta previa • Nursing management 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 IV fluids, packed RBCs, platelets, and fro-zen plasma for transfusion, if ordered; Rho(D) immune globulin, if the client is Rh negative; IV augmented oxytocin (Pitocin) to induce labor, if needed; and in cases of preterm labor, tocolytics (e.g., magnesium sulfate) to inhibit uterine contractions and corticosteroids (e.g., be-tamethasone) to enhance fetal lung maturity.

Precipitate Disorder

• labor that is completed in less than 3 hours from the start of contractions to birth. • A nullipara's cervix dilates faster than 5 cm per hour or the fetal head descends faster than 1 cm per 12 minutes. • multipara's cervix dilates faster than 10 cm per hour or the fetal head descends faster than 1 cm per 6 minutes • Potential fetal complications may include head trauma, such as intracranial hemorrhage or nerve damage, and hypoxia due to the rapid progression of labor

Hypotonic uterine dysfunction

• occurs during active labor (dilation more than 4 cm) when contractions become poor in quality and lack sufficient intensity to dilate and efface the cervix. • Factors associated with this ab-normal 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. • The major risk with this complication is hemorrhage after giving birth because the uterus cannot contract effectively to compress blood vessels.

Hypertonic uterine dysfunction

• occurs when the uterus never fully relaxes between contractions. • Contractions are ineffectual, erratic, uncoordinated, and involve only a portion of the uterus. • 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. • affects nulliparous women more than multiparous women

Prolonged pergnancy

• one that continues past the end of the 42nd week of gestation, or 294 days from the first day of the last menstrual period. • Maternal risk is related to the large size of the fetus at birth, which increases the chances that a cesarean birth will be needed. Other issues might include dystocia, birth trauma, postpartum hemorrhage, and infection. Mechanical or articial inter-ventions such as forceps or vacuum-assisted birth and labor induction with oxytocin may be necessary • Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of subcutaneous fat and muscle and meconium staining), and CPD. • Uteroplacental insufficiency, meconium aspiration, and intrauterine infection contribute to the increased rate of perinatal deaths

Administering oxytocin

• prepare the oxytocin infusion by diluting 10 units of oxytocin in 1,000 mL of lactated Ringer's solution or ordered isotonic solution. • Start the oxytocin infusion in mU/min or milliliters per hour as ordered. • During induction or augmentation, monitoring of the maternal and fetal status is essential. • 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 accord-ingly. • 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 nonreassuring FHR pattern occurs. • Perform or assist with periodic vaginal examinations to determine cervical dilation and fetal descent: cervical dilation of 1 cm per hour typically indicates satisfactory progress. • 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.

Cervical Ripening

• process by which the cervix softens via the breakdown of collagen fibrils. • It is the first step in the process of cervical effacement and dilation • 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. • The Bishop score helps identify women who would be most likely to achieve a successful induction. • 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 usu-ally indicate that a cervical ripening method should be used prior to induction

Calcium channel Blockers

• promote uterine relaxation by decreasing the influx of calcium ions into myometrium cells to inhibit contractions. • Administer calcium channel blockers (nifedipine) orally or sublingually every 4 to 8 hours as ordered. • Monitor the woman for hypotension, reflex tachycardia, headache, nausea, and facial flushing.

Placental Abruption

• refers to premature separation of a normally implanted placenta from the maternal myometrium. • *Risk factors include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology.* • Management of placental abruption depends on the gestational age, the extent of the hemorrhage, and maternal-fetal oxygenation perfusion/reserve status • the focus is on maintaining the cardiovascular status of the mother and developing a plan to deliver the fetus quickly. • A cesarean birth may take place quickly if the fetus is still alive with only a partial abruption. A vaginal birth may take place if there is fetal demise secondary to a complete abruption.

Multifetal Pregnancy

• refers to twins, triplets, or more infants within a single pregnancy • The most common maternal complication is postpartum hemorrhage resulting from uterine atony.

Cesarean Birth

• the delivery of the fetus through an incision in the abdomen and uterus. • The client is at risk for complications such as infection, hemorrhage, aspiration, pulmonary embolism, urinary tract trauma, thrombophlebitis, paralytic ileus, and atelectasis. Fetal injury and transient tachypnea of the newborn also may occur • Spinal, epidural, or general anesthesia is used for cesarean births. • The leading indications for cesarean birth 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 HIV status, and dystocia. • Fetal indications include malpresentation (nonvertex presentation), con-genital anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects), and fetal distress • Assist with diagnostic tests such as CBC, urinalysis, blood type and cross-match, ultrasound for fetal position and placental location, and an amniocentesis.

Umbilical cord Compression

• the protrusion of the umbilical cord alongside (occult) or ahead of the presenting part of the fetus • Prolapse usually leads to total or partial occlusion of the cord. • The fetus will die if the cord compression is not relieved. • cord prolapse is more common in pregnancies involving malpresentation, growth restriction, prematurity, ruptured membranes with a fetus at a high station, hydramnios, grandmultiparity, and multifetal gestation • When membranes are artificially ruptured, assist with verifying that the presenting part is well applied to the cervix and engaged into the pelvis. • Changing the woman's position to a modified Sims, Trendelenburg, or knee-chest position also helps relieve cord pressure. Monitor fetal heart rate, maintain bed rest, and administer oxygen if ordered. • If the mother's cervix is not fully dilated, prepare the woman for an emergency cesarean birth to save the fetus's life.

Oxytocin

• used for both artificial induction and augmentation of labor. • The most common adverse effect of oxytocin is uterine hyper-stimulation, leading to fetal compromise and impaired oxygenation • oxytocin has an antidiuretic effect, resulting in decreased urine flow that may lead to water intoxication. Symptoms to watch for include headache and vomiting. • 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