Chapter 10
The goal of oxytocin use in labor is to establish uterine contraction patterns that promote cervical dilation of about ______ cm/hr once in active labor.
1
what proportion of babies in the US are electively delivered, mainly for convenience
1/3 Labor induction should be performed only for medical indication; if done for nonmedical indications, the gestational age should be 39 weeks or more, and the cervix should be favorable. 2. Fetal heart tones have been documented as present by Doppler for 30 weeks. 3. It has been 36 weeks since a positive serum or urine pregnancy test was confirmed
Data show that outcomes for newborns are greatly improved when gestation is longer than ___ weeks
39
As long as fetal and maternal status are reassuring, cervical dilation of ____ cm should be considered the threshold for the active phase of labor
6 do not go to section before that
% of women considered candidates for a TOLAC to attempt a VBAC will have a successful vaginal birth
60-80
which bishop score indicates a favorable cervix for delivery
8+ 6 or less is unfavorable
Factors that increase the chances for a successful VBAC include:
A previous vaginal delivery, especially a previous VBAC. ● Spontaneous onset of labor (labor is not induced). ● Normal progress of labor, including dilation and effacement (thinning) of the cervix. ● Prior cesarean delivery performed because the baby's position was abnormal (e.g., breech). ● Only one prior cesarean delivery. ● The prior cesarean delivery was performed early in labor, and not after full cervical dilatation.
indications for induction of labor
Abruptio placentae Chorioamnionitis (intraamniotic infection) Fetal demise Gestational hypertension Preeclampsia, eclampsia Premature rupture of membranes Post-term pregnancy Maternal medical conditions (e.g., diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, or antiphospholipid syndrome) Fetal compromise (e.g., severe fetal growth restriction, isoimmunization, oligohydramnios)
contraindications for mechanical cervical ripening
Active herpes Fetal malpresentation Nonreassuring fetal surveillance History of prior traumatic delivery Regular contractions Unexplained vaginal bleeding Placenta previa Vasa previa Prior uterine myomectomy involving the endometrial cavity or classical cesarean delivery A history of a prior low transverse cesarean delivery was considered a contraindication to induction of labor. According to the ACOG Practice Bulletin on vaginal birth after previous cesarean delivery, induction of labor is not contraindicated in women with a prior low transverse cesarean delivery; however, use of prostaglandins should be avoided in these patients due to a significantly increased risk of uterine rupture. A relative contraindication to cervical ripening is ruptured membranes. No current evidence shows that cervical ripening followed by delayed induction of labor reduces the rate of cesarean delivery.
what to do in instance of meconium stained fluid
All infants with meconium in the amniotic fluid should have their nose, mouth, and pharynx suctioned as soon as the head is delivered (intrapartum suctioning) regardless of whether the meconium is thin or thick. Alert the neonatal team, as meconium-stained amniotic fluid is a condition that requires notification and availability of an appropriately credentialed team with full resuscitation skills, including endotracheal intubation. Infants with meconium-stained amniotic fluid, regardless of whether they are vigorous or not, should no longer routinely receive intubation. However, meconium-stained amniotic fluid is a condition that requires the notification and availability of an appropriately credentialed team with full resuscitation skills, including endotracheal intubation. Resuscitation should follow the same principles for infants with meconium-stained fluid as for those with clear fluid
nursing care for an amniotomy
Assess the FHR before, during, and immediately following ROM because of the risk of umbilical cord prolapse. Offer comfort and support to the woman, as the procedure may be uncomfortable. Assess the color, amount, and odor of amniotic fluid. Monitor FHR and UC pattern. Document the time of the AROM as well as the indication for amniotomy; amount, color, and odor of amniotic fluid; FHR characteristics before amniotomy; fetal response after the procedure; cervical status; and fetal station. Assess maternal temperature every 4 hours or more frequently if signs and symptoms of infection occur. Administer pericare, as the woman continues to leak fluid after AROM. Typically, nurses do not perform an amniotomy. There may be individual institutional policies allowing nurses to perform AROM under specific criteria.
considerations before diagnosis arrest of labor
At least 2 hours of pushing in multiparous women At least 3 hours of pushing in nulliparous women
assessment findings for post term birth
Category II or III FHR related to decreased amniotic fluid and uteroplacental insufficiency with aging placenta ● Meconium-stained fluid ● Women report increased anxiety and frustration with prolonged pregnancy ● Fetal macrosomia
how to facilitate second stage of labor
Coaching the woman in bearing-down efforts Minimizing the Valsalva maneuver by using open glottis push strategies detailed in Chapter 8 Maintaining adequate pain relief for the woman with labor epidurals Changing the maternal position to a more upright position to facilitate fetal descent Supporting the woman's involuntary pushing efforts
risk factors for dystocia
Congenital uterine abnormalities such as bicornate uterus. Malpresentation of the fetus such as occiput posterior, or face presentation. Cephalopelvic disproportion. Tachysystole of the uterus with oxytocin. Maternal fatigue and dehydration. Administration of analgesia or anesthesia early in labor. Extreme maternal fear or exhaustion, which can result in catecholamine release interfering with uterine contractility
risk factors for fetal dystocia
Contraction or narrowing of the pelvic inlet, the midpelvis, or the pelvic outlet Abnormal fetal presentation or position such as asynclitism, face, brow presentation, or breech or transverse lie (Table- 10-1) Fetal anomalies, such as hydrocephalus, and/or any other fetal anomaly that interferes with fetal descent through the birth canal Fetal macrosomia; birth weight greater than 4,500 g
what to do when inducing labor w oxytocin and category II or III HR occurs
Discontinue oxytocin. • Change maternal position to left lateral position. • Initiate IV hydration of at least 500 mL lactated Ringer's. • Administer O2 by nonrebreather mask at 10 L/min. • Consider terbutaline if no response. • Notify provider, observe, and reevaluate.
a syndrome that occurs when the body is breaking down blood clots faster than it can form a clot. This quickly depletes the body of clotting factors, leading to hemorrhage, and can rapidly lead to maternal death.
Disseminated intravascular coagulation always a result of another pathological process or injury
nursing actions for umbilical cord prolapse
Elevation of the presenting part. Occlusion of the cord may be partially relieved by lifting the presenting part off the cord with a vaginal exam. The examiner's hand remains in the vagina, lifting the presenting part off the cord until delivery by cesarean request assistance Recommend position changes such as knee-chest position or Trendelenburg to try to relieve pressure on the occluded cord (Fig. 10-18), administer O2 at 10 L/min by mask, and give IV fluid hydration bolus. Discontinue oxytocin and consider administration of a tocolytic agent to decrease uterine activity. Move toward emergency delivery. If birth is imminent, the provider may proceed with vaginal delivery. If birth is not imminent, anticipate and prepare for emergency cesarean section.
nurses unique role in oxytocin use and informed consent
Ensure informed consent has been obtained by providing information about induction and discussing the agents, methods, options, and risks (Gilbert, 2011). Nurses can play an important role in advocating for women who want to wait for labor to progress naturally but face pressure from their families or obstetric providers to undergo nonmedically indicated induction. Nurses can also play an important role in ensuring women have the information needed to make informed decisions regarding labor augmentation
nursing interventions for hypertonic uterine dysfunction
Evaluate for cause of labor dysfunction Hydrate to improve perfusion promote rest to break pattern of infrequent contractions (warms shower, quiet environment, minimal interruptions) Pain management to allow rest and prevent exhaustion
assessment findings of fetal dystocia
FHR may be heard above the umbilicus versus in the lower uterine segment; this is a sign that the fetus may be in position other than vertex. The SVE reveals buttocks or face when malpresentation is the cause of dystocia. The presenting part is not engaged in the maternal pelvis. There is no fetal descent through the pelvis
contraindications for amniotomy
Fetal head not engaged in the maternal pelvis Maternal infection such as HIV, viral hepatitis, or active genital herpes
assessment findings for chorioamnionitis
Fetal tachycardia (greater than 160 bpm for 10 minutes or longer) ● Maternal WBC count greater than 15,000 in the absence of corticosteroids ● Purulent fluid from the cervical os (cloudy or yellowish thick discharge confirmed visually on speculum examination to be coming from the cervical canal) ● Biochemical or microbiologic amniotic fluid results consistent with microbial invasion of the amniotic cavity Be alert for and report characteristic clinical signs and symptoms of chorioamnionitis, including: Maternal fever (intrapartum temperature higher than 100.4°F [37.8°C]). Significant maternal tachycardia (greater than 120 bpm). Fetal tachycardia (greater than 160 to 180 bpm). Purulent or foul-smelling amniotic fluid or vaginal discharge. Uterine tenderness. Maternal leukocytosis (total blood leukocyte count greater than 15,000 to 18,000 cells/µL). Hypotension. Diaphoresis. Cool or clammy skin.
nursing actions for external cephalic version
Fetal well-being and contraction pattern should be assessed by a nonstress test or biophysical profile before and after the procedure (ACOG, 2016). Testing should continue for at least 30 minutes after the procedure. Anti-D immune globulin should be given to Rh-negative mothers who have no plans for delivery within 72 hours after ECV. Offer comfort and support to the woman, as the procedure may be uncomfortable. Parenteral tocolysis (beta agonist) should be used if there are no contraindications. ECV should be attempted only in settings in which cesarean delivery services are readily available
risk factors for mechanical cervical ripening
Higher infection rate Premature rupture of membranes (PROM)
two types of mechanical cervical dilators
Hygroscopic dilators: placed in the cervix and promote dilation by water absorption. they expand over 12 to 24 hours as they absorb water. Absorption of water from the cervical tissue leads to expansion of the dilators and opening of the cervix balloon catheters: catheter is placed in the uterus and the balloon is filled. Direct pressure is then applied to the lower segment of the uterus and the cervix.
causes of labor dystocia
Includes lack of progressive dilation (passenger) lack of descent (passenger) and uncoordinated contractions (hypertonic or hypotonic).(powers)
indications and contraindications of induction w oxytocin
Indications: Post-term pregnancy Pregnancy-induced hypertension Preeclampsia/eclampsia Maternal medical conditions (e.g., diabetes mellitus, renal disease, chronic pulmonary disease, cardiac disease, chronic hypertension) Premature rupture of membranes (PROM) Chorioamnionitis Fetal stress or compromise, such as severe intrauterine growth restriction (IUGR), oligohydramnios, or isoimmunization Fetal demise History of rapid labors/distance from the hospital Psychosocial considerations Contraindications Previous vertical (classical) uterine scar or prior transfundal uterine scar Placental abnormalities such as complete placenta previa or vasa previa Abnormal fetal position Umbilical cord prolapse Active genital herpes Pelvic abnormalities
risks associated w membrane sweeping
Infection Bleeding from undiagnosed placental problem Unplanned ROM
an infection with resultant inflammation of any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua
Intraamniotic infection (IAI), also referred to as chorioamnionitis
cascade of events following labor induction that women need to be well informed on
Labor induction in the United States leads to an intravenous (IV) line, bed rest, and continuous electronic fetal monitoring (EFM), and frequently amniotomy, significant discomfort, epidural analgesia/anesthesia, and a prolonged stay on the labor unit.The use of oxytocin and prostaglandin agents increases the risk of fetal compromise during labor and birth, mainly as a result of uterine tachysystole and prolonged stay in the labor unit
primary considerations for titration of oxytocin
Labor progress and maternal-fetal response to the medication
risk factors for vasa previa risks associated with vasa previa
Low-lying placenta or a placenta previa ● Pregnancies in which the placenta has accessory lobes ● Multiple gestation ● Pregnancies resulting from in vitro fertilization ● Fetal asphyxia from cord compression ● Fetal death from exsanguination
incidence of hypertonic uterine dysfunction
Most common during latent phase (Prolonged latent phase) Most common in primagravida (1st time moms)
incidence and cause of precipitous labor
Most common for multiparas. Very rare for primigravidas. Can result from hypertonic contractions
risk factors for hypotonic uterine dysfunction
Multiparous women often have more problems in the active phase. Extreme fear may result in catecholamine release, interfering with uterine contractility.
complications of fetal dystocia
Neonatal asphyxia related to prolonged labor. Fetal injuries, such as bruising. Maternal lacerations. Cephalopelvic disproportion (CPD).
mcroberts manuever (diagram)
Pressure is applied above the pubic bone with the palm or fist; then the pressure is directed on the anterior shoulder both downward (to below the pubic bone) and laterally (toward the fetus's face or sternum) to abduct and rotate the anterior shoulder. Fundal pressure should be avoided, as it may further complicate impaction of the shoulder and also may cause uterine rupture.
risks associated w multiple gestation labor
Preterm labor ● Labor dystocia ● Antepartum hemorrhage (i.e., abruptio placentae) (Parfitt, 2016) ● Stillbirth
risks associated w amniotomy
Severe variable decelerations Bleeding from undiagnosed vasa previa or other placental abnormality Umbilical cord prolapse when presenting part is not engaged Intraamniotic infection increases with duration of the rupture. A Cochrane Review of trials noted early intervention with amniotomy and oxytocin appears to be associated with a modest reduction in cesarean births
risks associated with external cephalic version (ECV)
Severe variable decelerations Umbilical cord compression
risks associated w oxytocin induction
Tachysystole leading to Category II (indeterminate) or Category III (abnormal) FHR pattern is the primary complication of oxytocin in labor. Failed induction of labor: Failure to generate regular (e.g., every 3 minutes) contractions and cervical change after at least 24 hours of oxytocin administration, with artificial membrane rupture if feasible. Side effects of oxytocin use are primarily dose related; tachysystole and subsequent FHR decelerations are common side effects (ACOG, 2011). Water intoxication can occur with high concentrations of oxytocin with large quantities of hypotonic solutions, but usually only with prolonged administration with at least 40 mU/min.
most concerning side effect of oxytocin administration
Tachysystole, previously referred to as hyperstimulation, is excessive uterine activity and is the most concerning side effect of oxytocin because it can result in a progressive adverse effect on fetal status Complications of uterine tachysystole for the fetus include hypoxia that can lead to acidemia, worsening to acidosis, ultimately leading to brain damage and even fetal death
guidelines for vacuum assisted birth
The fetal head needs to be engaged and the cervix completely dilated. There should be a maximum of three attempts for a period of 15 minutes: the "three-pull rule." Cup detachment from the fetal head (pops off the vacuum) is a warning sign that too much pressure or ineffective force is being exerted on the fetal head. The physician should proceed with a cesarean birth when vacuum attempts are not successful not to exceed 500 to 600 mm Hg pressure
risks of umbilical cord prolapse
Total or partial occlusion of the cord, resulting in rapid deterioration in fetal perfusion and oxygenation, causes fetal hypoxia, and if not treated swiftly, can lead to long-term sequela, disability, or death
complications of precipitous labor
Uterine rupture, lacerations, postpartum hemorrhage, amniotic fluid embolism, fetal hypoxia
used to describe labor and vaginal birth in a woman who has had a prior cesarean birth
VBAC: vaginal birth after cesarean A trial of labor after cesarean (TOLAC) offers women the opportunity to achieve a VBAC
contraindications for labor induction
Vasa previa or complete placenta previa Transverse fetal lie Umbilical cord prolapse Previous classical cesarean birth Active genital herpes infection Previous myomectomy entering the endometrial cavity
appears to significantly decrease the risk of uterine rupture for women attempting VBAC.
Waiting for spontaneous labor, thus avoiding cervical ripening agents and oxytocin Misoprostol (prostaglandin E1) should not be used for cervical ripening or labor induction in the third trimester in women with prior uterine incisions and use of other prostaglandins is also strongly discouraged
indications for mechanical cervical ripening
When the woman has little or no cervical effacement When pharmacological methods are contraindicated, such as women with prior uterine incision
Management of chorioamnionitis
abx, antipyretics
In both spontaneous and induced labor, the diagnosis of an arrest disorder should not be made before the patient has entered the ______ phase.
active (6 cm dilated)
Rapid onset of respiratory distress that occurs during labor, delivery, or 30 minutes postdelivery (Parfitt, 2016) with severe hypoxia, hypotension, cyanosis, loss of consciousness, foaming at the mouth, pulmonary edema, uncontrolled bleeding from uterus, IV sites, or any other incisions due to coagulopathy, seizures, cardiac arrest, and prolonged late decelerations or bradycardia resulting from fetal hypoxi
amniotic fluid embolism/anaphylactic sydrome rare and unpredictable
the artificial rupture of membranes (AROM) to induce or augment labor with an amnihook during a SVE
amniotomy done by the primary care provider and only if an emergency delivery can be performed nearby
candidates for TOLAC/VBAC
an acceptable option for a woman who has undergone one prior cesarean delivery with a low transverse uterine incision, assuming there are no other conditions that would normally require a cesarean delivery such as placenta previa.
the size, shape, or position of the fetal head prevents it from passing through the lateral aspect of the maternal pelvis or when the maternal pelvis is of a size or shape that prevents the descent of the fetus through the pelvis.
cephalopelvic disproportion requires C section can rarely be diagnosed until labor has progressed for some time.
the process of physical softening, thinning, and dilating of the cervix in preparation for labor and birth
cervical ripening
2 pharmacologic cervical ripening agents
cervidil/dinoprostone misoprostol/cytotec
a nursing for 4 cleints of the l&d unit. which of the following actions should the nurse take first a. check the blood sugar of a gestational diabetic b. assess the vaginal blood loss of a client who is post spontaneous abortion c. assess the patellar reflexes of a client w mild preeclampsia d. check the fetal heart rate of a client who just ruptured membranes
d. check the fetal heart rate of a client who just ruptured membranes worried about cord compresison- causes: loss of amniotic fluid, interventions: reposition mom
symptoms of fluid overlod with oxytocin administration
decreased urine output, edema, increased blood pressure (BP), and pulmonary edema.
medical management of hypotonic uterine dysfunction
determine cause evaluate progression augment with oxytocin perform aniotomy consider c section
post term birth risk to mom and baby
difficulties during labor, an increase in injury to the perineum (including the vagina, labia, and rectum), and an increased rate of cesarean birth with its associated risks of bleeding, infection, and injury to surrounding organs to fetus: stillbirth macrosomia post-maturity syndrome, this refers to a fetus whose growth in the uterus after the due date has been restricted, usually due to a problem with delivery of placental blood flow to the fetus.decreased subcutaneous fat and lack vernix and lanugo. Meconium staining of the amniotic fluid, skin, membranes, and umbilical cord often is seen in association with a post-mature newborn. oligohydramnios meconium aspiration decreased placental reserve
induced labor
dilation greater than 6 cm with rupture of membranes, or 5 cm intact with no further dilation after 4 hrs of adeqaute contractions when progress slows provider will rupture membranes artificially
arrest of labor/
dilation of more than or equal to 6 cm dilation with membrane rupture and 4 hours or more of adequate contractions OR 6 hours or more of inadequate contractions and no cervical change
most common reason for primary cesarean sections
dystocia
difficult labor that is characterized by abnormally slow labor progress
dystocia results from abnormalities of the power, the passenger, or the passage often mistakenly made before the woman has entered the active phase of labor and, therefore, before adequate trial of labor
two terms used to characterize an abnormally long labor
dystocia failure to progress
a procedure in which the fetus is rotated from the breech to the cephalic presentation by manipulation through the mother's abdomen
external cephalic version performed as an elective procedure in nonlaboring women at or near term to improve their chances of having a vaginal cephalic birth.
may be caused by excessive fetal size, malpresentation, multifetal pregnancy, or fetal anomalies.
fetal dystocia
risks associated with hypertonic/hypotonic uterine dysfunction
for mom: exhaustion for baby: fetal intolerance asyphxia rt decreased placental perfusion
If oxytocin has been discontinued for 20 to 30 minutes, the FHR is reassuring, and no uterine tachysystole is present, oxytocin may be restarted at
half the rate that caused tachysystole and gradually increased every 30 minutes based on maternal-fetal response. If oxytocin has been discontinued for more than 30 to 40 minutes, exogenous oxytocin is metabolized; therefore, oxytocin must be restarted at the initial dose
uncoordinated uterine activity
hypertonic uterine dysfunction Contractions are frequent and painful but ineffective in promoting dilation and effacement.
occurs when the pressure of the UC is insufficient to promote cervical dilation and effacement
hypotonic uterine dysfunction woman makes normal progress during the latent phase of labor, but during active labor the UCs become weaker and less effective for cervical changes and labor progress
indications and risks associated with vacuum assisted labor
indications: prolonged second stage labor impending fetal compromise risks to mom:Vaginal and cervical lacerations ● Extension of episiotomy ● Hemorrhage related to uterine atony, uterine rupture ● Bladder trauma ● Perineal wound infection risks to baby: cephalohematoma -> increased risk of jaundice, intracranial/retinal hemorrhage, scalp lacerations or bruising
the stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus
labor augmentation
the deliberate stimulation of UCs before the onset of spontaneous labor to facilitate a vaginal delivery.
labor induction
cesarean birth- classical (vertical incision)
less common higher incidence of blood loss, infection, and uterine rupture vaginal birth not allowed later
what manuever can be performed to prevent shoulder dystocia
mcroberts
nursing interventions for ROM (whether spontaneous or artificial)
monitor fetal response note and document time and appearance of fluid (alert NICU if meconium stained) hygiene: clean up mom pain management will feel increased sense of pain w UC if no epidural is not present
what do you need to do before a external cephalic version
non stress test
a vaginal birth that is assisted by vacuum extraction or forceps
operative vaginal birth
the most common induction agent used worldwide.a peptide synthesized by the hypothalamus that is transported to the posterior lobe of the pituitary gland, where it is released in the maternal circulation in response to vaginal and cervical stretching. stimulates UCs response usually occurs within 3 to 5 minutes after IV administration begins, with a half-life of 10 minutes
oxytocin Synthetic oxytocin is identical to endogenous oxytocin
assessment findings for hypertonic uterine dysfunction
painful, frequent contractions with inadequate uterine relaxation and little cervical changes May be Category II (indeterminate) or Category III (abnormal) fetal heart rate (FHR) related to prolonged labor and inadequate uterine relaxation
factors influencing method of labor induction
parity, status of membranes (ruptured or intact), status of the cervix (favorable or unfavorable), and history of previous cesarean births. more successful in parous women than in nulliparous women
related to the contraction of one or more of the three planes of the pelvis.
pelvic dystocia The three contractions of the pelvic planes are: Inlet contraction, which occurs when the widest part of the pelvis is small. Midpelvis contraction, which is related to prominent ischial spines, convergent pelvic side walls, and a narrow sacrosciatic notch; this may arrest the descent of the vertex. Outlet contraction, which can be estimated by measuring the transverse diameter of the pelvis. Normally, the anteroposterior diameter is 14 cm.
serves as the fetal lungs in utero
placenta
contraindications to labor augmentation
placenta or vasa previa, umbilical cord presentation, prior classical uterine incision, active genital herpes infection, pelvic structural deformities, or invasive cervical cancer.
refers to the abnormal condition of the newborn resulting from prolonged pregnancy
post maturity
a pregnancy that has reached or extended beyond 42 weeks' gestation,
post term
Labor that lasts less than 3 hours from the onset of contractions to the time of birth
precipitous labor Women who experience a precipitous labor often have higher anxiety and pain levels related to the rapid and intense labor experience. will have hypertonic uterine contractions and possibility for category II or III FHR
cesarean section: low transverse incision
preffered method easier to perform, less blood loss, fewer infecitons VBAC possible
hypertonic uterine dysfunction in early labor may be referred to as
prodromal labor
nursing management of cord prolapse
prompt recognition SVE, apply pressure to presenting part get assistance position pt in extreme trendelemburf position administer oxygen get IV access monitor FHR if possible prepare for immediate delivery
oxytocin is always infused via a
pump administered intravenously and is piggybacked to a mainline IV solution at the port most proximal to the venous site
logistical reasons to induce labor and special considerations
reasons: risk of rapid labor, distance from the hospital, or psychosocial indications at least one of these should be met Ultrasound measurement at less than 20 weeks' gestation supports gestational age of 39 weeks or greater. Fetal heart tones have been documented as present for 30 weeks by Doppler ultrasonography. It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test result. Testing for fetal lung maturity should not be performed and is contraindicated when delivery is mandated for fetal or maternal indications. Conversely, a mature fetal lung maturity test result before 39 weeks' gestation, in the absence of appropriate clinical circumstances, is not an indication for elective labor induction.
nursing interventions for precipitous labor
remain in the room manage pain Anticipate potential bruising, PP hemorrhage, and lacerations Anticipate potential newborn hypoxia, CNS depression, bruising
pelvic dystocia risk factors assessment findings medical management nursing actions
risk factors: small pelvis, abnormal pelvic shape asssment: delayed descent of fetal head medical: Evaluate the pelvis for contraction of one or more of the planes of the pelvis. Evaluate the descent and engagement of the fetal head nursing: SVE. to evaluate the progress of labor and fetal descent into pelvis
begins when the cervix becomes fully dilated and ends with delivery of the neonate
second stage of labor
a fetal death after 20 weeks' gestation
stillbirth/intrauterine fetal demise
nursing actions for hypotonic uterine dysfunction
stimulate uterine activity- ambulate, hydrate IV and PO, augment with oxytocin evaluate progress via SVE provide emotional support and inform family of progress minimize SVE and maintain perineal cleanliness to prevent ROM
involves digital separation of the chorionic membrane from the wall of the cervix and lower uterine segment during a vaginal exam done by a primary care provider to stimulate labor
sweeping/stripping the membranes
excessive uterine activity and can be either spontaneous or induced. It is defined as more than five contractions in 10 minutes, averaged over 30 minutes Five or more UCs in 10 minutes over a 30-minute window. • A series of single UCs lasting 2 minutes or longer. • UCs occurring within 1 minute of each other. • Insufficient return of uterine resting tone between contractions via palpation or intraamniotic pressure above 25 mm Hg between contractions via IUPC.
tachysystole
risks with pharmacologic cervical ripening
tachysystole The major risk of the above prostaglandin preparations is uterine hyperstimulation. The woman and fetus must be monitored for contractions, fetal well-being, and changes in the cervical Bishop score
The fetus can move through the birth canal most effectively when
the head is flexed and is presenting anterior to the woman's pelvis (occiput anterior position) This allows the smallest diameter of the fetal head to enter the maternal pelvis and the most flexible part of the fetal body, the back of the neck, to adapt to the curve of the birth canal
occurs when the cord lies below the presenting part of the fetus
umbilical cord prolapse
Accurate dating of pregnancy using early prenatal care and ultrasonography is advised before cervical ripening and induction of labor. Mistimed cervical ripening and induction can result in
unplanned iatrogenic preterm birth
rare but very serious most frequent cause is separation of previous uterine scar tell sign is searing pain
uterine rupture
risks of VBAC
uterine rupture fetal death
Decrease or discontinue oxytocin in the event of
uterine tachysystole or Category II (indeterminate) or Category III (abnormal) FHR
occurs when fetal vessels unsupported by placenta or umbilical cord traverses the membranes over the cervix. defined as abnormal fetal blood vessels that run through the fetal membranes, over or near the endocervical os, and are unprotected by the placenta or umbilical cord
vasa previa
uterine dystocia
weak or uncoordinated uterine contractions in labor, characterized as either hypertonic or hypotonic uterine dysfunction
contraindications for VBAC
● Prior vertical (classical) or T-shaped uterine incision or other uterine surgery (Fig. 10-13) ● Previous uterine rupture ● Pelvic abnormalities ● Medical or obstetric complications that preclude a vaginal birth ● Inability to perform an emergent cesarean birth if necessary because of insufficient personnel such as surgeons, anesthesia, or facilit
risk factors for chorioamnionitis
● Prolonged rupture of membranes. ● Obstetric risk factors for intraamniotic infection at term have been delineated, including low parity, multiple digital examinations, use of internal uterine and fetal monitors, meconium-stained amniotic fluid, and the presence of certain genital tract pathogens
assessment findings for uterine rupture
● Severe tearing sensation, burning or stabbing pain, and contractions ● Uterine tachysystole and/or hypertonus and vaginal bleeding ● Maternal assessment findings may include signs and symptoms of hypovolemic shock, such as hypotension, tachypnea, tachycardia, and pallor. ● Fetal response is related to hemorrhage and placental separation and may include sudden fetal bradycardia or prolonged late or variable decelerations present even prior to the onset of abdominal pain or vaginal bleeding (Parfitt, 2016). ● Ascending station of the fetal presenting part
benefits of VBAC
● Shorter length of hospital stay and postpartum recovery (in most cases) ● Fewer complications, such as postpartum fever, wound or uterine infection, thromboembolism (blood clots in the leg or lung), need for blood transfusion Fewer neonatal breathing problems
