Week 7

Dystocia What does it mean? How does it disturb the 5 P's

Dystocia = Means difficult birth* From disturbance to one or more of the 5 P's Abnormalities of the birth canal, uterus, cervix, or vagina = Passageway Faulty presentation of the fetus, umbilical cord, and/or placenta; Fetal size and number of fetuses = Passenger Insufficient or uncoordinated uterine forces; Inadequate voluntary forces during the 2nd stage of labor = Powers Maternal position (supine, horizontal positioning is less optimal compared to vertical positioning) = Position Fear of childbirth, lack of support, unaddressed psychological barriers = Psyche (Book) Dysfunctional labor (dystocia): -Dystocia refers to a lack of progress in labor for any reason. -Dysfunctional labor is defined as a long, difficult, or abnormal labor These can be caused by any of the following: -Ineffective uterine contractions or maternal bearing-down efforts (the powers) (can be compromised when large amounts of analgesic medications are given) · Contractions that are ineffective in causing dilation* -Fetal causes, including abnormalities of presentation, position or development (the passenger) -Alterations in the pelvic structure including abnormalities of the maternal bony pelvis or soft tissue abnormalities

Best reason to use tocolytic therapy? Purpose of cesarean birth?

**The best reason to use tocolytic therapy is to achieve sufficient time to administer glucocorticoids in an effort to accelerate fetal lung maturity **The basic purpose of cesarean birth is to preserve the well-being of the mother and her fetus

What is the most effective available pharmacologic pain relief method for labor?

*Epidural anesthesia and analgesia is the most effective available pharmacologic pain relief method for labor. It is used by a majority of women in the U.S. "Pharmacological measures for pain management should be implemented before pain becomes so severe that catecholamines increase and labor is prolonged" -- triggers fight or flight response that inhibits UCs/birth (blood is shunted away from non-critical organs like the abdomen)

Contraindications to subarachnoid (spinal) and epidural blocks? (3) Effects of an epidural block on the newborn?

-Active or anticipated serious maternal hemorrhage (any anesthetic technique that blocks the sympathetic fibers can produce significant hypotension that can endanger the mother/fetus) -Maternal hypotension -Coagulopathy (if woman is receiving anticoagulant therapy or has a bleeding disorder) Effects of epidural block on the newborn: analgesia or anesthesia during labor and birth has little or no lasting effect on physiologic status of the newborn. There is no evidence that administration of these has a significant effect on the child's later mental or neurologic development

Post dural puncture headache Treatment?

-Caused by a leakage of CSF after epidural/spinal block -Increased pressure on the brain by a decrease of fluid surrounding your brain. ----More present when standing versus laying down Treatment: -Oral analgesics -Bed rest (lying flat) -Hydration -Epidural blood patch (injection of 10 to 20 ml of autologous blood at the site of the attempted epidural puncture)

Contraindications to spinal/epidural anesthesia?

-Patient refusal -Hypovolemia* -Coagulopathies* -Infection at site of needle insertion -Spinal column deformity/injury -Hx Toxic/allergic reaction to local anesthetic

Risks of Oxytocin Induction? (3)

-Uterine Hyperstimulation** (Can cause the following): -Placental abruption -Uterine rupture -Fetal distress Increased risk of postpartum hemorrhage* -Uterus becomes hypotonic (lazy) from too much Pitocin, cannot clamp down on blood vessels and pt bleeds Water intoxication: -Oxytocin has anti-diuretic affect* -If we are running with hypotonic IV fluids, we can give the pt water intoxication* (this is why we only give oxytocin in ISOTONIC solutions) Uterine Hyperstimulation = 1. Persistent tachystole (>5 UC/10 min) (Defined as greater than 5 contractions per 10 min (period of rest is short)) 2. A single UC lasting > 2 minutes may also be called a tetanic contraction 3. UCs occurring within one minute of each other. (Polysystolic) ***The most common cause of a tachysystolic, polysystolic or hypertonic contraction pattern is oxytocin or prostaglandin administration We are concerned about oxygenation to the uterus during uterine hyperstimulation* Oxytocin or prostaglandin stimulation is the most common cause of these hyperstimulation's so we have to be very carful when giving them

Other uses of magnesium sulfate besides for PTL

Administering magnesium sulfate to women giving before 32 weeks to reduce incidence of cerebral palsy in their infants* (Given to women who are at least 24 weeks but less than 32 weeks gestation) No longer recommended for stopping preterm labor (???) but can reduce cerebral palsy in women anticipating preterm birth at less than 32 weeks' gestation

Obstetric emergencies Amniotic Fluid Embolus (AFE) What is it? Predisposing conditions? Care? S/S?

Amniotic Fluid Embolus (AFE): Also known as anaphylactoid syndrome of pregnancy is rare; characterized by sudden and acute onset of hypotension, hypoxia, and hemorrhage caused by coagulopathy (impaired clot formation) -AFE is considered to be unpreventable* and cause is unknown** -AFE is neither an air embolism or amniotic fluid related (although its timing suggests a breach of the normal physiologic barriers between the woman and fetus) AFE occurs during labor, birth or within 30 min after birth; Respiratory and cardiovascular collapse along with coagulopathy occur (like anaphylaxis) The exact factor that initiates AFE is unknown but particles of feta debris (vernix, hair, skin cells, meconium) found in amniotic fluid were thought to be responsible for initiation the syndrome. Neonatal outcome in AFE cases is poor (20-60% mortality rate) Predisposing conditions: rapid labor, meconium-stained amniotic fluid, tears into uterine and other large pelvic veins that permit an exchange of fluids between maternal and fetal compartments. Older maternal age, post term pregnancies, labor induction or augmentation, eclampsia, cesarean birth, forceps/vacuum assisted births, placental abruption, or placenta previa, hydramnios. Care: Cesarean birth should be performed to help the woman improve and help fetal survival. The nurse's immediate response is to help with resuscitation efforts. Mom will need ventilatory support. Oxygenate, prepare for intubation, maintain CO and replace fluid losses, position woman on her side. Signs: Respiratory distress (Restlessness, dyspnea, cyanosis, pulmonary edema, respiratory arrest,) Circulatory collapse (hypotension, tachycardia, shock, cardiac arrest,) Hemorrhage (coagulation failure, bleeding, lacerations)

What is an Amniotomy?

Amniotomy: the artificial rupture of membranes (AROM) done to induce labor when the cervix is favorable (ripe) or to augment labor is progress begins too slow. Usually this is done in combination with oxytocin induction. The presenting part of the fetus should be well engaged and well applied to the cervix prior to the procedure to prevent cord prolapse. FHR is assessed before and immediately after to detect any changes; Transient tachycardia is common

Definition of: Analgesia Anesthesia Choice of these?

Analgesia -Absence of pain Anesthesia -Partial or complete loss of sensation CHOICE OF ANALGESIA AND ANESTHESIA: -Desires of the patient -Circumstances/contexts -Stage/phase of labor -Urgency of the situation -Indications/contraindications -Availability, skills and judgment of the anesthesia provider

Obstetrical Emergencies Anaphylactoid syndrome of pregnancy (ASP) Cause? Why does it happen?

Anaphylactoid syndrome of pregnancy (ASP) -Also known as amniotic fluid embolism* Occurs when Amniotic fluid containing particles of debris (e.g., vernix, hair, skin cells, or meconium) enters the maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse (acts like any other embolism, can travel to lungs and cause shock/anaphylactic type symptoms) Happens right before or during delivery/birth or right after. She sits up, Codes High mortality

Pharmacologic Treatment of PTL Anti-Prostaglandins Calcium Channel Blockers Beta-Adrenergic Agents (beta-sympathomimetics)

Anti-prostaglandins - inhibit uterine contractions by decreasing vasoconstrictive prostaglandin activity - example: Indomethacin (*Indocin) (Powerful NSAID) -PRECAUTION: causes premature closure of the PDA in the fetus...use is restricted to cases of likely survivability in fetuses <32 weeks -Once PTL has been diagnosed, we want to reduce prostaglandin activity. Indomethacin is a potent Anti prostaglandin. This medication is recommended for short term (48 hours or less) use <32 weeks. There are risks to the fetus from this medication. Prostaglandins in fetal circulation help maintain the patency of the ductus arteriosus, one of the cardiac shunts that directs oxygenated blood to fetal organs, Premature closure of this shunt from antiprostaglandin medication is a risk, so fetal surveillance while mother's are on this drug is necessary. -Women with PTL are advised to avoid sexual intercourse to minimize cervical stimulation and because semen contains prostaglandins as well Calcium-Channel Blockers - prevent entry of calcium into the muscle cell to inhibit contractility - example: Nifedipine (*Procardia) -Side effects: hypotension Beta-Adrenergic Agents (beta-sympathomimetics): -Terbutaline (*Brethine) - relaxes smooth muscles (bronchial and uterine) -Route - SQ, PO, or IV (IV no longer used, PO nor longer recommended, SQ < 48-72 hrs only) -Dose - .25 mg SQ and repeat in 30 mins PRN as rapid tocolytic, -Titration Goal - decreased uterine activity and pulse rate >100 and <130 BPM -Antagonist - Propranolol (*Inderal) beta-blocker -Terbutaline is a beta sympathomimetic, whichrelax smooth muscles like the bronchioles and the uterus. -This drug acts like a cardiovascular stimulant, unlike magnesium. -It does not raise the blood pressure, but it does increase the pulse. Therefore, we use the pulse rate to titrate medication doses. -The medication is given SQ, again on a short term basis due to the risks of fluid retention and pulmonary edema. -Because this is one of our fight or flight drugs (like epinephrine), this medication increases the blood sugar, so is not ideal for use with diabetic patients. -These are short term drugs and we also give them before mechanical movement of the baby (we do not want contractions to occur while we are trying to reposition the baby in utero) (Book) B-Adrenergic Agonist: Like Terbutaline (Brethine) relaxes smooth muscle, inhibiting uterine contractility and causing bronchodilation · Watch for tachycardia, cardiac arrest, tremors, hypotension, chest pain, pulmonary edema Prostaglandin Synthetase Inhibitors (NSAIDs): like Indomethacin (Indocin,) relaxes uterus smooth muscle by inhibiting prostaglandins Calcium Channel Blockers: Nifedipine (Adalat) relaxes smooth muscle of the uterus by blocking calcium entry

Augmentation of labor What are common methods?

Augmentation of Labor: the stimulation of UCs after labor has started spontaneously and progress is unsatisfactory. Usually done to manage hypotonic uterine dysfunction that results in the slowing down of the labor process. Oxytocin infusion and amniotomy are common augmentation methods** Noninvasive methods like emptying the bladder, position changes, hydration should be attempted before invasive interventions

Adjuvant Medication for PTL (preterm labor) Bethamethasone (Celestone) or Dexamethasone

Betamethasone (Celestone) or Dexamethasone: -Glucocorticoid Steroid -Increases fetal lung surfactant production -Reduces incidence and severity of NRDS (neonatal resp. distress syndrome) Administered to mother 24-34 wks with PTL -Dose - 6 - 12 mg IM X two doses - 12-24 hours apart -Considerations - masks s/sx infection Note that steroids have the effect of suppressing the inflammatory response, so they mask signs and symptoms of infection. As such, they should generally not be used in mothers with ruptured membranes, as their risk for infection is increased and we want to be able to detect developing infection.

Incompetent Cervix (And Cervical Cerclage to treat it) Cause? Etiology? Diagnosis? Management? When is cerclage placement offered (length of cervix)

Cervical Cerclage = a ring or loop used to hold the cervix closed, strengthens the cervix Incompetent cervix = Spontaneous, premature dilation of the cervix during the second trimester of pregnancy Cervical Cerclage to Treat Incompetent Cervix: -One cause of late miscarriage is recurrent premature dilation of the cervix (incompetent cervix), which has traditionally been defined as passive and painless dilation of the cervix during the second trimester. -This definition assumes an all-or-nothing role for the cervix: it is either competent or incompetent. Current thinking is that cervical competence is variable and exists as a continuum that is determined in part by cervical length. Etiology: -Etiologic factors include a history of previous cervical trauma such as lacerations during childbirth, excessive cervical dilation for curettage or biopsy, or ingestion of diethylstilbestrol (DES) by the woman's mother while pregnant with the woman. -Multiple gestation alone does not produce reduced cervical competency or justify prophylactic cervical cerclage. Other causes are a congenitally short cervix and cervical or uterine anomalies. Diagnosis: -Reduced cervical competence is a clinical diagnosis, based on history. Short labors, recurring loss of the pregnancy at progressively earlier gestational ages, advanced cervical dilation at the time of first presentation for care, and a history of prior cervical surgery or trauma suggest reduced cervical competence Ultrasound examination during pregnancy is used to diagnose this condition objectively. A short cervix (less than 25 mm) is indicative of reduced cervical competence. Often the short cervix is accompanied by cervical funneling (beaking) or effacement of the internal cervical os Management: -Medical management consists of bed rest, pessaries, antibiotics, anti-inflammatory drugs, and progesterone supplementation -Surgical management, with placement of a cervical cerclage, may be chosen instead. -During pregnancy the McDonald technique is often the procedure of choice. In this procedure suture is placed around the cervix beneath the mucosa to constrict the internal os of the cervix -A cerclage may be placed prophylactically or as a rescue procedure once the cervix has been found to be effaced or dilated. -A prophylactic cerclage is usually placed at 11 to 15 weeks of gestation. The cerclage is electively removed (usually an office or a clinic procedure) when the woman reaches 37 weeks of gestation, or it may be left in place until spontaneous labor begins. -Occasionally the cerclage is left in place and a cesarean birth performed. Cerclage placement is offered if the cervical length falls to less than 20 to 25 mm before 23 to 24 weeks Risks of the procedure include premature rupture of membranes (PROM), preterm labor, and chorioamnionitis. Although no consensus has been reached, 24 weeks is often used as the upper gestational age limit for cerclage placement (Iams). Follow-up Care at Home: -The woman will likely be on bed rest for a least a few days immediately following cerclage placement. She will also probably be advised to avoid sexual intercourse until after a postoperative check. -The woman must understand the importance of initial activity restriction at home and the need for close observation and supervision. -Tocolytic medications may be prescribed to prevent uterine contractions and further dilation of the cervix -Additional instruction includes the need to watch for and report signs of preterm labor, ROM, and infection. -Finally, the woman should know the signs that would warrant an immediate return to the hospital, including strong contractions less than 5 minutes apart, ROM, severe perineal pressure, and an urge to push.

Cesarean Section Birth/Delivery Indications? CDMR by maternal request?

Cesarean section is the surgical delivery of a baby through an incision in the woman's abdomen and uterus **Sagittal cut (most often) -Rates have risen to a national level of > 30% (33%), 1 in 3 births in the U.S is a surgical birth -C-sections do not appear to help infant mortality rate* -The number of babies who die in the first year of life in the U.S ranks our nation among the lowest developed nations (lower than some underdeveloped nations) -Surgical birth does not necessary improve OB outcomes Indications: -CPD -FTP (non-progressive labor) -Non-reassuring (Category 3) fetal heart rate patterns -Malpresentations -Prior C/S with classical uterine incision (vertical) -Previous uterine surgery** -Genital herpes with active lesion or positive culture* -Umbilical cord prolapse -Placenta previa /abruption -Obstructive tumors -Multiple gestation in some cases **Any woman who has had a prior C-section has a higher likelihood of having another. Our goal is to prevent the initial (first) C-section #1 reason for C-section = repeat C-section (HIV with no HAART and high viral load also may need C-section delivery) CDMR by Maternal Request -C-section is requested on the absence of medical or obstetrical indication for cesarean delivery (4-18%) Reasons: -fear of labor and vaginal birth -desire for convenience -desire to protect pelvic structures from risk of future prolapse (not evidence-based) Increased risks from: -Hemorrhage -Longer hospitalization -Increased costs -Neonatal respiratory morbidity** -Subsequent placenta previa/accreta -Subsequent uterine rupture -Informed consent* (giving the patients all the info, C-sections can be more dangerous? Unless in situations where they are needed) Nursing responsibilities -Patient teaching and support -Preop teaching to help with postop management -Witness consent signature* (Nurse witnesses formed consent) -Abdominal prep, foley insertion, IV hydration, antacid administration, pre-op checklist -Scrub, circulate, recover (Book) Cesarean birth: birth of the fetus through transabdominal incision of the uterus. Can be planned or unplanned Indications for Cesarean birth: · Maternal = specific cardiac diseases · Fetal = non-reassuring fetal status, malpresentation (breech or transverse lie,) active maternal herpes lesions · Maternal-fetal = cephalopelvic disproportion, placental abruption, placenta previa, hx of previous cesarean birth, cesarean birth on maternal request -C-section maternal requests should not be done before 39 weeks gestation* -A low transverse (horizontal) incision is most done during C-sections; Vertical incisions are rare and associated with a higher chance of uterine rupture in subsequent pregnancies · Low horizontal incisions also allow VBAC (vaginal birth after cesarean) to be done is subsequent pregnancies · In emergencies, general anesthesia will most likely be used unless the woman already has an epidural block* (After women pass flatus they can resume a regular diet - after anesthesia with C-section)

Cervical ripening methods Chemical Agents (PGE1 and PGE2)

Chemical agents: Giving prostaglandin E1 or E2 before induction can help ripen (soften and thin) the cervix. Advantages of using prostaglandins include decreased oxytocin use PGE1: less expensive and more effective than PGE2 is associated with higher risk for uterine tachysystole with abnormal FHR (not yet approved by FDA.) -PGE1 ripens the cervix, making it softer and causing it to dilate and efface (stimulates more uterine contractions) -Used for preinduction cervical ripening before oxytocin induction of labor** -Should NOT be used if woman has a hx of previous cesarean birth or other major uterine surgery -Recommended initial dose is 25mg intravaginally PGE2: in the form of vaginal insert (strip) is more expensive but has major advantage of easy removal should adverse reactions occur* -PGE2 ripens the cervix making it softer and causing it to dilate and efface (stimulates UCs.) Dinoprostone is the only FDA approved medication for cervical ripening of labor* -Should NOT be used if woman has a hx of previous cesarean birth or other major uterine surgery -Dosage of 10mg -Inserted transvaginally into the posterior fornix of the vagina -Stay in bed for 2 hours afterwards

What is Chorioamnionitis? S/S? Risk factors? Treatment? Occurs after what?

Chorioamnionitis: is a bacterial infection of the amniotic cavity that is a major complication for mother/baby at any gestational age S/S: Maternal fever, maternal/fetal tachycardia, uterine tenderness, and purulent amniotic fluid in the absence of another evident source of infection are seen Occurs most often after membranes rupture or labor begins; organisms that are part of the normal vaginal flora ascend into the amniotic cavity Risk factors: prolonged membrane rupture, multiple vaginal examinations, use of internal FHR and contraction monitoring methods, young maternal age, low socioeconomic status, nulliparity, preexisting infections are all risk factors Fetal risk factors include increased risk for resp. distress syndrome, cerebral palsy, pulmonary/CNS damage, meningitis.

Combined spinal-epidural analgesia Benefits?

Combined spinal-epidural analgesia: also called a walking epidural; a small amount of opioid or combination of opioid and local anesthetic is injected intrathecally to rapidly provide analgesia; It blocks pain function without compromising motor function The combination of an opioid with the local anesthetic agent reduce the dose of anesthetic required (preserving a greater degree of motor function.) **Naloxone should be available for use if the RR decreases to less than 12 breaths/min or if the O2 saturation decreases to less than 89%. Administration of oxygen by nonrebreather mask can also be initiated. Notify anesthesia care provider.

Contraindications to Tocolysis?

Contraindications to Tocolysis: Preeclampsia, bleeding or hemodynamic instability, intrauterine fetal demise, lethal fetal anomaly, non-reassuring fetal status, chorioamnionitis, PROM**, maternal fever, and fetal tachycardia

Effects of IV opioids during labor for pain relief

Effects of IV opioids during labor for pain relief: -Injectable opioids are systemic analgesics that help with pain throughout the entire body without causing total loss of movement or feeling in the body -Common ones are fentanyl, morphine, Remifentanil, Nalbuphine, Butorphanol Pethidine (Demerol) - can take a week after birth for drug to leave newborn body. (Most common opioid given outside of US) All opioids cross placenta and can cause side effects to baby (less likely to cause side effects when given through epidural**) Opioids not given in second stage of labor because it can affect baby breathing during birth IM injections of opioids are not as effective* -PCA pump is associated with better patient pain outcomes Pro of IV opioids: not shown to increase risk of C-section birth Epidurals shown to be more effective of pain and side effects are less* Epidural/Spinal block = gold standard for labor*

Epidural block Spinal Block Combined spinal-epidural block Epidural space? Subarachnoid space?

Epidural block = catheter is placed in your back in an area tight beneath the spinal cord -Takes longer to work (10 min to feel effects) -Other drugs can be given through this catheter Spinal block = given with smaller needle and dose of drug (given into spinal fluid.) usually only given once, wears off faster, works immediately Combined spinal-epidural block (CSE): you get the immediate pain relief of the spinal block and continuous pain relief of the epidural (called walking epidural) Epidural Space = -The space outside the dura mater of the brain and spinal cord -For epidural block Subarachnoid (intrathecal) space = -The space within the spinal canal -The space where the spinal cord lives! -The space containing cerebral spinal fluid -For spinal block

Where are fetal heart tones best heard in a breech labor?

FHT are best heard AT or above the umbilicus for a breech labor (lower abdomen for vertex* cephalic labor)

General anesthesia Indications? Risks? Nursing responsibilities?

General Anesthesia Indications: -Emergency Cesarean Section -Cesarean Section with other surgical procedures -Surgical birth when regional anesthesia fails or is contraindicated -Cardiopulmonary arrest -Immediate uterine relaxation needed - uterine inversion Risks of General Anesthesia: -Failed Intubation -Pulmonary aspiration -Adverse reactions to anesthetic medications Nursing Responsibilities: -Verify Informed consent -Pre-op antacid administration -Assistance at induction -**Cricoid pressure - to prevent pulmonary aspiration -Assistance at emergence -Post-anesthesia care

General anesthesia -What percentage of C-sections use GA? -Risks? -Cricoid pressure? -Post-anesthesia care? -Informed consent

General anesthesia: rarely used for uncomplicated vaginal births and only used for about 10% of cesarean births in the United States. -Major risk are associated with difficulty or inability to intubate and aspiration of gastric contents. -Mom's need to be NPO before surgery. Wedge should be placed under one of the woman's hips to displace the uterus and prevent hypotension from compression of great vessels. *Sometimes the nurse is asked to apply cricoid pressure before intubation as the woman begins to lose consciousness; this blocks the esophagus and prevents aspiration should the woman vomit or regurgitate. Postanesthetic care priorities are to maintain an open airway and cardiopulmonary function and to prevent postpartum hemorrhage. Women who are waking up from general anesthesia will require pain medication soon after regaining consciousness. Informed consent: A description of the various anesthetic techniques and what they entail is essential to informed consent. Teaching should take place before labor in the 3rd trimester, so the woman has time to consider alternatives. Nurses play a role in informed consent by clarifying and describing procedures or acting as the woman's advocate The nurse must monitor for medication adverse reactions (especially anaphylaxis)

How do we promote fetal lung maturity in a preterm labor?

Glucocorticoids to the mother to accelerate fetal lung maturity by stimulating fetal surfactant production; It is one of the most effective and cost-efficient interventions for preventing morbidity and mortality associated with preterm birth. It has been shown to reduce resp. distress syndrome, intraventricular hemorrhage, NEC, and death in neonates. ACOG recommends all women between 24-34 weeks get a single course when preterm birth is threatened More than 2 doses of antenatal glucocorticoids are not recommended** Betamethasone (12mg IM) and Dexamethasone (6mg IM) are used *

Methods for managing shoulder dystocia? (HELPERR)

H - Call for HELP E - Evaluate for Episiotomy (Create more room) L - Legs: McRoberts Maneuver (hyper-flexion woman's legs backwards and towards stress - relieves shoulder dystocia in about 80% of cases) P - External Suprapubic Pressure (Do not apply fundal pressure, this will worsen it) E - Enter: Rotational Maneuvers R - Remove (deliver) the Posterior Arm first may help top shoulder drop down R - Roll the patient to her hands and knees "Gaskin Maneuver" Methods for reducing shoulder dystocia = Super pubic pressure (do not apply fundal pressure it will make everything worse)

What do hormones and neurotransmitters released in response to stress cause? (related to labor)

Hormones and neurotransmitters released in a response to stress (catecholamines) can cause dysfunctional labor* Anxiety can also cause increased levels of stress related hormones that act on smooth muscles of the uterus and can cause dysfunctional labor

Forceps and Vacuum Extraction What are the indications for use, prerequisites (absolute and relative)

Indications for Use: -Non-reassuring (Category 3) fetal heart rate with imminent birth -+2 or +3 station but bad FHR pattern -We want to accelerate birth in this case -Maternal exhaustion -Maternal disease Prerequisites for Use (absolute) -Complete cervical dilation -Engagement of fetal head in the pelvis (or other presenting part) -Ruptured membranes -Cephalopelvic proportionality (head can fit through pelvis) Prerequisites for Use (relative) -Empty bladder and rectum -Anesthesia

Vacuum Extraction Complications to mother/fetus? Nurses role?

Indications: -Same as with forceps, but used primarily to maintain descent between maternal pushes Advantages of vacuum over forceps: -Fewer maternal risks Limitations to vacuum extractor -Cannot apply to aftercoming head in breech presentations -Cannot apply to face Potential Complications from Vacuum Use: Maternal -Perineal or cervical lacerations Fetal -Cephalohematoma or caput succedaneum (bruised/swollen area on baby head) -Ulceration, or necrosis of vacuum application site -Scalp laceration or abrasion -Cerebral irritation or intracranial hemorrhage (severe cases) Nurse's Role in Forceps or Vacuum Assisted Deliveries: -Preparation - equipment, patient, anticipation -Explanation and support -Monitoring -Documentation -Document number of pulls, number of contractions -Assistive interventions (oxygen administration, pitocin titration, suprapubic pressure) maybe transport to operating room for C-section (Book) Vacuum-Assisted Birth: involves attaching a vacuum cup to the fetal head, using negative pressure to assist in the birth of the head. Not used to assist in birth before 34 weeks gestation · Informed consent, completely dilated cervix, ruptured membranes, engaged head, vertex presentation, and no suspicious on CPD required · Risk to the newborn include cephalohematoma, scalp lacerations, and subdural hematoma. The mother should still push during contractions. The newborn is also at risk for hyperbilirubinemia and neonatal jaundice as bruising resolves · The nurse should assess the FHR frequently during the procedure

Labor induction and augmentation What does induction mean? Augmentation? Induction trends? Role of cervical ripening? Bishops score?

Induction = making a woman give birth when her body is not starting the process itself Augmentation = things that add to the preexisting labor pattern (she is already in labor and needs assistance for it to keep progressing) Induction Trends: -Rates have more than doubled in past two decades 9.5% (1989) - 23.3% (2012) -Indications for induction - elective vs indicated (medically) -Don't perform inductions electively prior to 39 weeks gestation Role of cervical ripening: -Part of induction process* may be done because their body has not entered in spontaneous labor -Bishop's score (cervical scoring system) to let us know how ready the mother is to enter spontaneous labor or to indicate if we need to induce labor Mechanical and chemical agents (to help with cervical ripening) · Prostaglandins · Laminaria · Foley balloon

Induction of labor? What is the most common method? When can elective induction be done? How does Bishops Score influence induction?

Induction of labor: is the chemical or mechanical initiation of uterine contractions before their spontaneous onset to bring about birth. IV oxytocin (Pitocin) and amniotomy are the most common methods used in the U.S. Elective induction is when labor is initiated without medical indication (for convenience of the mom or HCP, for obese moms or those with maternal diabetes to give birth before complications arise.) Should not be done until the fetus reaches 39 weeks gestation* Transverse lie (shoulder presentation) and other breech presentations may be contraindications to induction* Bishops Score: Success rates for inductions are higher when the condition of the cervix is favorable. Cervical ripeness is the most important indicator of successful induction. Bishop's score is a rating system used to evaluate inducibility -A score of 8 or more = the cervix is soft, anterior, 50% of more effaced and dilated 2 cm or more and that the presenting part is engaged (good)

Pharmacologic Treatment of PTL Magnesium Sulfate Mechanism of action, route, dose, antagonist, titration goals?

Magnesium Sulfate (first line tocolytic): -Mechanism of Action: Central Nervous System Depressant, Anticonvulsant, and smooth muscle relaxant (uterus) -Route: IV piggy-backed to mainline and titrated through a constant infusion pump -Dose: 4-6Gm Loading dose given over 10-30 minutes, followed by a continuous maintenance infusion of 1-3Gm/hr -Antagonist: Calcium Gluconate - 10ml of a 10% solution (1 Gm) slow IV push -Titration Goal: Therapeutic Serum Mg Level -Normal - 1-2 mg/dl -*Therapeutic - 5-7 mg/dl -Toxic - > 10 mg/dl (Resp. depression, apnea occur) Four very different classifications of drugs are used as tocolytics during pre-term labor. None of them are effective for significant prolongation of pregnancy, but all of them have benefits for suppressing contractions long enough to buy some time (usually 24-48 hours) for steroids to be administered and have an impact on fetal surfactant levels. Each of the medications has undesirable side effects. Selection of the particular tocolytic depends on gestational age as well as any contraindicating conditions in specific mothers. Magnesium sulfate, which is used to prevent seizures in patients with preeclampsia, can also be used to suppress preterm labor. As a CNS depressant and weak vasodilator, is relaxes smooth muscles such as the uterus. This medication also has a neuro protective effect on the fetus, and in cases of extreme prematurity, reduces the risk for intracranial hemorrhage of the fragile blood vessels of the small newborn. Understanding that this is a CNS depressant, nurses need to be sure and check vital signs frequently, with particular attention to respiratory rate, level of consciousness, and DTR's. Because MG is excreted by the kidneys I&Os it is also important to monitor I&Os. We are of course doing continuous fetal monitoring for UC activity and Fetal response. Women will often complain of feeling hot and flushed during the loading dose and subsequently rather tired or sluggish. When mg levels exceed the therapeutic range, respiratory depression, unconsciousness, and apnea can occur. This risk is greatest in women with compromised renal function, when the kidneys cannot clear the MG well. **Can cause pulmonary edema/fluid overload (Book) Suppression of uterine activity: Using tocolytics (medications given to arrest/stop labor after uterine contractions and cervical change have occurred. No drugs are currently approved for use by the FDA, we use asthma or hypertension or anti-inflammatory or analgesic agents "off label" to suppress preterm labor. -Tocolytics do not reduce the rate of preterm birth but are used to delay birth long enough to allow time of maternal transport to a level 3 or 4 neonatal care center Magnesium sulfate: is the most used tocolytic agent* because maternal/fetal adverse reactions are less severe and less common than with the B-adrenergic agonists. CNS depressant, relaxes smooth muscle (uterus.) IV fluid should be 40g in 1000ml · Magnesium sulfate depresses the function of the CNS so the nurse will need to assess RR, deep tendon reflexes and LOC frequently to make sure signs of toxic levels are not occurring** · Watch for RR below 12 breaths/min · *Calcium gluconate would be used if toxicity occurs** · Total IV intake should not be limited to 125 ml/hour**

Management of PTL (preterm labor) Lifestyle vs pharmacologic? Betamethasome?

Management of PTL: -Modify or mitigate risk factors (modify activities, rest, hydration, no really hard jobs) -Early recognition and intervention -Treat underlying causes if possible (UTI treatment which will reduce uterine muscle irritability and strop contractions) -Modify activity - lifestyle, work-related, sexual -Judicious hydration -Pharmacologic tocolysis (beta-mimetics, calcium channel blockers, anti-prostaglandins) -Monitoring maternal and fetal status -Accelerate fetal lung maturation Tocolytic medications, which are types of drugs that reduce or eliminate uterine contractions, can be administered. When pre-term birth is anticipated, we will administer betamethsome, as steroid to the mother. This medication stimulates fetal production of surfactant, a phospholipid which reduces surface tension around the lungs and improves lung compliance during breathing. -Accelerating fetal lung maturity through the use of betamethasone between 24-34 weeks gestation has been shown to improve neonatal outcomes and hospitalization time. -Given IM not IV! Needs to be given in 2 doses 24 hours apart** Pharmacologic tocolytic therapy derives from 4 different classifications of medications to treat preterm labor o None are FDA approved for tocolysis (using all off label) o None particularly effective for long term prevention of PTB o Goal of using tocolytic therapy - "buying time" (Book) Prevention: smoking cessation, prophylactic progesterone supplementation. Since more than half of preterm births occur in women without obvious risk factors, teaching symptoms of labor is important* -Change in type of vaginal discharge, increase amount of vaginal discharge, pelvic or lower abdominal pressure, mild abdominal cramps with or without diarrhea, regular or frequent contractions or uterine tightening (often painless,) ruptured membranes. Lifestyle modifications: bedrest, hydration, limited work (modified bedrest may be better to reduce clots and muscle stasis.) Restriction of sexual activity to promote pelvis rest. Home care: modify the woman's environment and keep essential items within reach. What to do if symptoms of preterm labor occur: Stop what you are doing, lie down on side, drink 2-3 glasses of water or juice, wait 1 hour, if symptoms get worse, call doc, or go into facility. If symptoms go away, tell HCP at next visit. If symptoms come back, call HCP.

What are some maternal risk factors that can complicate the second stage of labor? (Pushing stage?) Fetal factors that can complicate the second stage (pushing) of labor?

Maternal Risk Factors (Second stage of labor = Pushing stage) -Cardiac Disease -Severe Pre-eclampsia -Diabetes -Prolonged Labor -Poor Pushing Effort -Maternal exhaustion -Bladder Distension Fetal Factors: -Macrosomia = Shoulder Dystocia (fetal body too large from maternal diabetes or post term preg) -Malpresentation -Malformations -Multiple Gestation -Asynclitic position** (Ear down on shoulder, creates a larger head diameter and is harder to birth. The fetal head is no longer in line with the birth canal) (see pic)

Maternal hypotension with decreased placental perfusion: S/S? Interventions?

Maternal hypotension with Decreased Placental Perfusion: -S/S: maternal hypotension (20% decrease from prebook baseline level or < 100 mm Hg systolic,) fetal bradycardia, absent or minimal fetal heart rate (FHR) variability. -Interventions: 1) Turn the woman to lateral position* or place a pillow or wedge under one hip to displace uterus 2) Maintain IV infusion at rate specified or increase rate of flow per hospital protocol 3) Administer oxygen by nonrebreather mask (10-12 L/min) 4) Elevate the woman's legs 5) Notify the obstetric and anesthesia health care providers 6) Administer IV vasopressor per protocol 7) Stay with woman, monitor BP and FHR every 5 min until condition is stable. Ephedrine or phenylephrine (vasopressors) are used to increase maternal BP**

What are the maternal and fetal indications for induction? Bishops score? What score indicates a ripe cervix

Maternal: -PROM (prior to labor onset) -Post-dates pregnancy -Infection -Maternal disease -Pre-eclampsia -Oligohydramnios Fetal: -IUGR -Antepartum indicators -+CST* (Positive contraction stress test) -Decreased BPP (biophysical profile—Fetal oxygenation in utero) -Fetal death Bishop's Score: -Scores are assigned in 5 categories and total score ranges from 0 - 13 -Scores greater than 7 indicate a "ripe" cervix - prepared for labor onset or amenable to induction -Range of score 0-13 > 7 = ripe cervix 7 or under = need to do something before trying to induce labor so the cervix can respond better

Mechanical/physical methods of cervical ripening What do they include?

Mechanical and physical methods of ripening: Mechanical dilators ripen the cervix by stimulating the release of endogenous prostaglandins. Balloon catheters are used (Foley catheter) that result in pressure and stretching of the lower uterine segment and the cervix Amniotic membrane stripping or sweeping can be done by inserting a finger into the internal cervical os and rotating it 360 degrees. (Causes release of prostaglandins and oxytocin.) Physical methods include sexual intercourse (prostaglandins in the semen,) nipple stimulation, walking, blue cohosh and castor oil, acupuncture can all stimulate prostaglandin release and help self-induce labor*

Obstetric emergencies Meconium-Stained Amniotic fluid What does it indicate? What is the major risk involved? Care we provide?

Meconium-Stained Amniotic Fluid: -Indicates that the fetus has passed meconium (first stool) before birth (usually amniotic fluid is stained green*) -This can be due to normal physiologic function of passing stool, be hypoxia induced peristalsis, or happen due to umbilical cord compression -The major risk is the development of meconium aspiration syndrome (MAS) - causes a severe form of aspiration pneumonia Care: involves gathering equipment that may be necessary for neonatal resuscitation. Having one person in the room that can perform endotracheal intubation. · Immediately after birth = assess the newborn RR, heart rate, muscle tone. · Suction only the newborns mouth and nose using a bulb syringe or large bore suction catheter if the baby has strong RR, good muscle tone and HR > 100 · Suction using trachea and meconium aspiration device if the baby has decrease RR, decreased muscle tone and HR < 100

What is uterine tachysystole?

More then 5 contractions in 10 min OR a series of single contractions lasting > 2min OR contractions of normal duration occurring within 1 min of each other

Nitrous Oxide (N2O) during labor Benefits? Contraindications? Nursing considerations?

Nitrous Oxide (N2O): -Systemic drug, inhalant. Helps manage pain without loss of feeling or muscle movement -Used for more than 100 years (but use is rare in US) -For maximum pain management, mother should start inhaling 30-45 seconds before the contraction Benefits of Nitrous Oxide: -No loss of motor or sensory function -Rapid onset of action and rapid clearance (30-60 seconds for both) -No recognized effect on FHR, APGAR -Self-administration increases sense of control -Comparatively less risky and costly -Does not have side effectives towards baby like injectable opioids do (can be used through all stages of labor) Contraindications of Nitrous Oxide: -Absolute contraindications to the administration of nitrous oxide include the presence of a potential space the gas could fill (ex.pneumothorax, intraocular surgery, bowel obstruction or middle ear surgery) -Inability to hold the mask from neuromuscular, cognitive, or motor impairment Nursing Considerations of Nitrous Oxide -Pt teaching for timing of inhalations to achieve peak analgesia (start 30-45 seconds before next UC begins)* -Partner teaching -Monitor analgesic adequacy -Monitor and manage side/toxic effects...respiratory depression (unlikely at recommended concentrations), nausea/vomiting (5-36%), dizziness (39%), dysphoria/restlessness (rare)

Nitrous Oxide for analgesia How does it work? Side effects?

Nitrous Oxide for Analgesia: Also called laughing gas, is administered in a 50:50 mix with oxygen with a blender device and a mask that is only help by the woman. It does not completely reduce pain but reduces their perception to pain; causes euphoria and decreases anxiety. -Main side effects are nausea and dizziness. -Nitrous oxide is safe for both mom and fetus and does not affect uterine activity.

Nursing priorities for spinal/epidural anesthesia? Complications?

Nursing Priorities: -Verify Informed Consent -Prehydration (IV bolus) -Assist with positioning for procedure -Frequent monitoring -VS -FHR/UC -Pain level/anesthetic level -Repositioning/fall prevention/safety COMPLICATIONS: -Hypotension - 2º sympathetic blockade from local anesthesia agents vasodilation -Backache -Toxic/allergic reaction to local anesthetic - rare -Epidural hematoma -Inadvertent Dural Puncture - spinal headache -High block if epidural (volume) is injected into subarachnoid space -Infection · PREVENTION OF HYPOTENSION: -Left uterine displacement* -500 ml to 1000 ml fluid bolus prior to epidural block -*Please monitor your patient's blood pressure frequently! TREATMENT OF HYPOTENSION: -Increase left uterine displacement -Increase rate of intravenous fluids IF HYPOTENSION IS NOT RESOLVED -Administer Ephedrine 5 to 10 mg IV -Phenylephrine 50 to 100 mcg IV -Administer oxygen by face mask -Raise legs*

Opioid agonist analgesics How do they work? -Demerol -Fentanyl

Opioid agonist analgesics: Stimulate major opioid receptors U and K; they have no amnesic effect but create a feeling of well-being/euphoria. Can inhibit uterine contractions so they should not be given until labor is well established unless they are being used to enhance therapeutic rest during prolonged early phase of labor. (Meperidine, fentanyl, remifentanil) Meperidine Hydrochloride (Demerol): -Opioid agonist analgesic; causes less resp. distress than morphine -Stimulates both U and K receptors to decrease the transmission of pain impulses -IV: 25-50 mg every 1-2 hours -Adverse effects: tachycardia, sedation, nausea, vomiting, dizziness, altered mental status, urinary retention Fentanyl (Sublimaze): -Short acting synthetic opioid agonist analgesic; rapidly crosses placenta so it is present in fetal blood within 1 min. -Stimulates both U and K opioid receptors to decrease the transmission of pain impulses -IV: 50-100 ug every hour -Adverse effects: sedation, resp. depression, nausea, and vomiting **Nalaxone is antidote (Narcan) is the antidote for both these drugs

Opioid agonist-antagonist analgesics How do they work? Side effects? -Nubain

Opioid agonist-antagonist analgesics: an agonist is an agent that stimulates a receptor to act, an antagonist is a agent that blocks a receptor or a medication. An opioid agonist-antagonist are agonists at K opioid receptors and either antagonists or weak agonists at U opioid receptors These mixed opioids provide adequate analgesia without causing significant respiratory depression in the mother or neonate. Higher doses do not produce additional resp. depression and are less likely to cause nausea and vomiting. Not suitable for women with an opioid dependence because the antagonist activity could precipitate withdraw symptoms** Nalbuphine Hydrochloride (Nubain) -Opioid agonist-antagonist analgesic -Stimulates K receptors and blocks or weakly stimulates U receptors. Less resp. depression and other side affects compared to opioid agonist analgesics. -Less nausea/vomiting; has effect similar to morphine -Not suitable for women with an opioid dependence because the antagonist activity could precipitate withdraw symptoms**

Opioid antagonists -How do they work? What drug can they not reverse effects of? Narcan

Opioid antagonists: like naloxone (Narcan) can promptly reverse the CNS depressant effects (respiratory depression.) CANNOT reverse the effects of normeperidine though. If we give Narcan, the laboring mom needs to be told the pain will return with the administration of the opioid antagonist. Narcan blocks both U and K receptors from the effects of opioid agonists. Opioid antagonists like Narcan are contraindicated for opioid dependent women because it can cause withdraw symptoms.

Opioid side effects seen in mother/baby?

Opioids provide sedation and euphoria, but their analgesic effect in labor is limited. The pain relief they provide is incomplete, temporary, and more effective in the early part of active labor. All opioids cause respiratory depression, vomiting, dizziness, altered mental status, euphoria, decreased gastric motility, delayed gastric emptying and urinary retention. (absent or minimal FHR variability during labor and significant neonatal resp. depression can be caused from opioids.) Opioids can inhibit uterine contractions and should not be administered until labor is well established unless they are being used to enhance therapeutic rest during prolonged early phase of labor.

Use of Oxytocin for induction? Adverse effects? What dose do we start with? What is the goal?

Oxytocin: hormone that is normally produced by the posterior pituitary to stimulate uterine contractions and milk ejection. Synthetic oxytocin (Pitocin) may be used to induce or augment labor that is progressing too slowly because of inadequate UCs. Adverse effects: Placental abruption, uterine rupture, unnecessary cesarean birth are hazards that can occur as well as postpartum hemorrhage and infection and fetal hypoxemia and acidemia The goal of oxytocin is to produce contractions of normal intensity, duration and frequency using the lowest dose of medication possible* -AEB 200-220 MVUs and one contraction every 2-3 min lasting 80-90 seconds and strong to palpation** Used for labor induction and augmentation and to also control postpartum bleeding Always given by infusion pump, secondary line, 10/20 units 1000ml or 30 units 500ml Starting dose of 1 milliunit/min and increase by 1-2 milliunits/min no more frequently than every 30-40 min is recommended**

Pelvis dystocia? Soft tissue dystocia? Cephalopelvic disproportion? Why is breech labor slower?

Pelvis dystocia: contractures of pelvic diameter that reduce the capacity of the bony pelvis. (Can be due to immature pelvic size or bad pelvic shapes) Soft tissue dystocia: results from obstruction of the birth passage by an anatomic abnormality other than that involving the body pelvis (uterine fibroids, ovarian tumors, full bladder/rectum) Cephalopelvic disproportion: (CPD) is disproportion between the size of the fetus and the size of the mother's pelvis. Fetal macrosomia is associated with maternal diabetes/obesity and is a cause. The fetus cannot fit through the maternal pelvis to be born vaginally. Breech labor may be slower because the breech is not as effective in dilating wedge as the fetal head is

What are pharmacologic methods used to relieve discomfort in the first, second, vaginal and Caesarea birth stages? Definition of Sedatives, anesthesia, analgesia?

Pharmacologic measures for pain management should be implemented before pain becomes so severe that catecholamines increase and labor is prolonged* Sedatives: reduce anxiety and promote sleep Anesthesia: encompasses analgesia, amnesia, relaxation, and reflex activity. IT abolishes pain perception by interrupting the nerve impulses to the brain Analgesia: refers to the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness. First stage of birth: -Opioid agonist analgesics -Opioid agonist-antagonist analgesics -Epidural (block) analgesia -Combined spinal-epidural (CSE) analgesia -Nitrous oxide Second stage: -Nerve block analgesia and anesthesia -Spinal block, epidural block, CSE analgesia, local infiltration anesthesia. Pudendal block -Nitrous oxide Vaginal birth: -Local infiltration anesthesia -Pudendal block -Epidural block analgesia and anesthesia -Spinal block anesthesia -CSE analgesia and anesthesia -Nitrous oxide Cesarean Birth: -Spinal block anesthesia -Epidural block anesthesia -General anesthesia

Bedrest vs activity restriction for PTL?

Physiologic and psychologic effects of long-term bedrest PLUS no documented benefit on PTL/PTB = strict bedrest not recommended** Restricted activity includes modifications of normal patterns to increase rest periods and decrease gravitational effects Activity Restriction to Manage PTL: Planning (anticipating needs during this time): -Preparation for rest periods ("at hand") -Help with other children -Meals/hydration -Diversions (family life, finances) -Stairs (modify living arrangements so she is not constantly using stairs) -Balance (meds that cause hypotension, be slow when getting up)

What is a post term pregnancy? Risk factors? Clinical manifestations? Care management and teaching?

Post term pregnancy: is one that reaches 42 week gestation or more. (many pregnancies are misdiagnosed as post term due to inaccurate recall of LMP) Risk factors are obesity, male fetus, genetic factors Clinical manifestations are maternal weight loss of about 3lbs a week, and decreased uterine size (loss of amniotic fluid), meconium in amniotic fluid, advanced bone maturation (hard fetal skull) Risk of macrosomia increases with post term pregnancy (large fetal body) which can cause shoulder dystocia and other fetal injuries Decrease of amniotic fluid increases risk of cord compression (resulting in hypoxemia) and there's an increased risk for meconium aspiration. Post maturity syndrome is seen as a decrease in subcutaneous fat, lacks lanugo, has dry cracked skin, long nails, and meconium staining on body Care management: if the cervix is favorable, induction is done at 41 weeks (increases rate of perinatal mortality after 41 weeks gestation.) We need to be careful because the aging placenta can produce disruption of O2 transfer to the fetus during contractions, compression of the umbilical cord and variable or prolonged decelerations. Teaching: includes performing daily fetal movements, assessing for signs of labor, going to hospital if membranes rupture

Forceps Injuries to mother/fetus?

Potential Complications from Use of Forceps: -**Injury is more likely to occur with Forceps than with vacuum extractor -Forceps are metal instruments; considerable force placed on head of baby and maternal reproductive organs Maternal -Lacerations (vaginal, cervical, perineal) -Hemorrhage -Uterine rupture -Bladder/rectal trauma -Fractured coccyx Fetal -Skull injuries (from pressure of forceps around head) -Neurologic injuries -Lacerations to face, ear, or scalp -Hematomas (Book) Forceps Assisted Birth: when an instrument with two curved blades is used to assist in the birth of the fetal head. Locks prevent the forceps from crushing the skull. · Indications for this include a prolonged second stage of labor and the need to shorten the second stage for maternal reasons (exhaustion.) · The use of forceps assisted birth is decreasing and being replaced with vacuum birth and c-section · The woman's cervix must be fully dilated to prevent lacerations and hemorrhage. Bladder should be empty, presenting part must be engaged, vertex presentation preferred, membranes must be ruptured so that the fetal head can be firmly grasped by forceps. If a decrease in FHR occurs, the forceps are removed and reapplied **Compression of the cord between fetal head and the forceps will cause a decrease in FHR. FHR needs to be assessed, reported and recorded before and after application of the forceps.

Precipitous labor?

Precipitous Labor: Labor that lasts LESS than 3 hours from onset of contractions to the time of birth (happens way too fast.) Fetal complications include hypoxia and sometimes intracranial trauma related to rapid birth.

What is premature/pre-labor rupture of membranes (PROM)? What about preterm PROM (pPROM)? Most common maternal complication of pPROM? Care management for the woman with PROM (at term and pre term?)

Premature/prelabor rupture of membranes (PROM): is the spontaneous rupture of the amniotic sac and leakage of amniotic fluid beginning before the onset of labor at any gestational age Preterm prelabor rupture of membranes (preterm Prom/pPROM): is membrane rupture before 37 weeks gestation -Preterm PROM most likely results from pathologic weakening of the amniotic membraned caused by inflammation, stress from UCs, or other factors that increase intrauterine pressure -Infection of the urogenital tract** is a major cause of pPROM **Chorioamnionitis is the most common maternal complication of preterm PROM (placental abruption, hemorrhage, sepsis, and death are other complications) Care plan for preterm PROM: -At term Preterm PROM = the best option is labor/birth (being induced) because infection is the greatest maternal/fetal risk -Preterm PROM between 34-36 weeks = active pursuit of labor and birth; immediate birth has the best outcomes even though these babies will be born a little early, they have low morbidity/mortality rates -Preterm PROM < 32 weeks = women will be hospitalized to try to prolong the pregnancy; Birth at this stage has greater risk than the risk for infection that comes with preterm PROM. Prolonging pregnancy is out goal unless intrauterine infection, significant vaginal bleeding, placenta abruption or other issues arise -Conservative management of PROM includes fetal assessments daily (increased risk of fetal cord compression,) NST, BPP, daily fetal movement counts -ACOG recommends women with preterm PROM between 24-34 weeks receive antenatal glucocorticoids -7-day course of broad-spectrum antibiotics (ampicillin, amoxicillin, erythromycin) is administered to prolong the time between membrane rupture and birth, decrease chorioamnionitis, reduce infections, and complications like hemorrhage. -Signs for infection is a major part of client teaching when preterm PROM occurs; Teaching includes showing woman how to keep genitals clean, signs of infection (fever, foul smelling vaginal discharge, maternal/fetal tachycardia.) -If chorioamnionitis develops, the woman is placed on broad-spectrum antibiotics and birth is accomplished.

Prematurity and low birth weight statistics

Preterm Birth (PTB) - 9.8% (2017) -#1 contributor to low-birth-weight incidence in the US (birth after 20th but before 37th completed week of pregancy) -#2 cause of infant mortality North American Stats: -Highest incidence in African Americans (50%> compared to white women) (13.3% vs 8.9%) -In US we see about a 9.8% rate of premature birth Low birth weight statistics -Preterm labor/birth contribute to LBW rate -LBW = born less than 2500G -LBW = associated with increased mortality and morbidity of neonates -LBW rates were declining since 2006, has been reversing in 2016 though (loss of progress) -Also, the increase in LBW births is disproportionate; twice as high in the African American population as in the Hispanic or Caucasian populations. This statistic raises concerns about health care disparities among minority groups and offers nurses opportunities to target preventative care toward these vulnerable patients.

Preterm Labor (PTL) Definition? Cause? Risk factors? S/S? What is an incompetent cervix?

Preterm Labor (PTL) Definition: The onset of uterine contractions between 20 and 37 weeks gestation with cervical change (associated with cervical effacement, dilation, or both.) -Contractions without cervical change is not considered to be premature labor, because no cervical change means that the risk for premature birth is unlikely. If there is cervical change without uterine contractions, we may be seeing an abnormality of cervical integrity called incompetent cervix. -This condition can result in early pregnancy loss, but often before the 20th week of pregnancy. -In cases like this, women will often present with a history of multiple miscarriages in the early second trimester. -When ruling out cases of PTL, cervical change can be determined by digital exam and/or by ultrasound measurements of cervical length, which is a more sensitive and quantifiable method for determining early and subtle changes in effacement or thinning of the cervix. Percentage of PTB by Cause: -Premature rupture of membranes- 30% -Preterm labor (no known cause) - 25% -Bleeding during pregnancy (antepartum hemorrhage)- 20% -Hypertensive disorders of pregnancy- 14% -Weak cervix (incompetent cervix)- 9% Other- 2% Risk Factors for PTL: -Previous preterm birth is the #1 risk factor** -Despite the number of risk factors for preterm labor, > 50% of cases have no identifiable risk factors* -25% preterm births are iatrogenic* (c-sections/inductions of labor for either indicated or elective reasons) Backing up a bit, we just took a look at the primary cause of preterm birth but we also need to review the risk factors for PTL, which may or may not result in a premature delivery. -Several factors are associated with an increased risk for PTL, including multiple gestation, maternal diseases and other pregnancy complications we have discussed in class, infection, and psychosocial conditions such as high levels of life stress, IPV, poor general health, and poor access to healthcare. -Although many risk factors are identified as contributors to PTL, many cases have no identifiable etiology. Primary prevention strategies that address risk factors associated with preterm labor and birth are less costly in human and financial terms than the high-tech and often lifelong care required by preterm infants and their families. Signs and Symptoms of PTL: -Contractions: not necessarily painful tightening's of the uterine muscle at regular intervals (true contractions are irregular, regular contractions are cause for concern**) -Menstrual-like cramps: Dull aching of a rhythmic or continuous nature in lower abdomen -Low backache: Unrelieved by position changes and possible radiation of discomfort to the front of the abdomen -Abdominal cramps: Intestinal discomfort with or without diarrhea -Pelvic pressure: Constant or intermittent with possible urinary frequency -Increase or change in vaginal discharge: In type, amount color, and/or frequency Signs and symptoms of PTL can be vague and nonspecific, leading to the mistaken conclusion that they are due to other causes like GI disorders or normal pregnancy symptoms.Some of these symptoms are...

Preterm labor is based on 3 major diagnostic criteria, what are they? Spontaneous vs indicated preterm births? Preterm, very preterm, moderately preterm and late preterm dates?

Preterm labor = regular contractions along with change is cervical effacement or dilation or both Preterm labor is based on three major diagnostic criteria: 1) Gestational age between 20 - 36 6/7 weeks 2) Regular uterine activity accompanied by a change in cervical effacement, dilation, or both 3) Initial presentation with regular contractions and cervical dilation of at least 2 cm Spontaneous preterm birth: birth occurring following early initiation of the labor process with the absence of maternal or fetal illness (Make up 75% of all preterm births) Indicated preterm births: iatrogenic, they occur as a means to resolve maternal or fetal risk related to continuing pregnancy Preterm birth = any birth that occurs between 20 and 36 6/7 weeks gestation -Preterm birth weight has increased slightly in U.S Very preterm = < 32 weeks' gestation -Most infant deaths and most serious morbidity occur among the infants who are born before 32 weeks' gestation* Moderately preterm = 32-34 weeks' gestation Late preterm = 34- 36 6/7 weeks gestation -Late preterm infants are at an increased risk for early death and long-term health problems when compared with infants who are born full term

Obstetrical Emergencies Prolapsed Umbilical Cord What is it? Contributing factors? What to do when this happens?

Prolapsed Umbilical Cord: -Occurs when cord lies below the presenting part of the fetus (umbilical cord presentation (funic)) (delivers before the baby's presenting part) Less common, can also occur with PROM (causing cord to come down towards fetal head) especially when baby not engaged well in pelvis Contributing factors include: -Long cord (longer than 100 cm) -Malpresentation (breech) (more room for cord to come down in front of presenting part) -Transverse lie -Unengaged presenting part* When a prolapsed cord is detected = it will obstruct a safe birth because with each contraction, the cord will be compressed, and circulation is severely decreased. Usually, a prolapsed cord is cause for immediate transfer to OR and C-section. We need to elevate the baby up and off the cord, and place mother in a position where gravity favors this (Knee chest position, or a modified SIMs position)

Obstetric emergencies Prolapsed umbilical cord What is it? Contributing factors? Interventions/treatment? Signs?

Prolapsed Umbilical Cord: -Occurs when the umbilical cord lies below the presenting part of the fetus. It can be occult (hidden) as well. -Contributing factors include longer cord (over 100cm,) malpresentation (breech or transverse lie,) or an unengaged presenting part (leaving room for the cord to be compressed.) Polyhydramnios (causes presenting part to not fit snuggly in lower uterine segment), rupture of membranes, and small fetus can cause cord to prolapse as well Care: includes prompt recognition of the condition, hypoxia occurs from prolonged cord compression that result in CNS damage or fetal death. Pressure on the cord may be relieved by the examiner putting gloved hand into the vagina and holding the presenting part off the umbilical cord Modified SIMS position and Trendelenburg (knee chest) position help gravity keep pressure of the presenting part off the cord. If mom is fully dilated, forceps or vacuum birth can be done but C-section is most likely to be performed. Signs: abnormal FHR and pattern (bradycardia, absent or minimal variability, and variable or prolonged decelerations,) inadequate uterine relaxation and bleeding. Do not attempt to put the cord back into the cervix if it is outside of the vagina** can ruin it more.

Cervical ripening agents Prostaglandins (E1, E2)? Mechanical dilators? Oxytocin?

Prostaglandins: -naturally secreted in most body cells (hormone) -act on target tissues to regulate body functions (dilation/constriction, inflammation) -Antagonists - NSAIDS, ASA, COX-2 inhibitors (These constrict vessels, play role in uterine contractions and help make cervix more ripe) -E1 (Misoprostil {Cytotec}) -E2 (Dinoprostone {Cervidil}) -F2α (Carboprost {Hemabate}) Cytotec (E1) -Black box alert. -GI drug, we use it off label during labor/delivery** -*Each tablet contains 100 micrograms of misoprostil **Typical pre-labor dose = 25 mcg intra-vaginal -One tab = 100mcg. We need to divide tab equally into 4 parts to get a 25mcg portion. (this can cause issues, what if we don't divide it properly) -Can use in post-partum hemorrhage as well (in larger doses and different route) E2 (Dinoprostone {Cervidil}) -E2 can be delivered in gel form, timed released infusion of gauzed covered tape* -Tape goes into vagina, lays behind cervix -Advantage over cytotex = this medication can be removed if pt has exaggerated response -(This is more expensive than cytotex so is not used as often) Mechanical dilators -Device placed into or around the cervix that slowly forces the cervix to begin to thin/dilated -Flowey balloon* -We think mechanical cervical dilation will produce release of prostaglandins to help with labor, or that the force/gravity from balloon will cause cervix to open more Oxytocin (Pitocin) -Oxytocin = Endogenous - hormone secreted by posterior pituitary -Stimulates uterine contraction (uterotonic) and milk ejection -Exogenous Oxytocin = Pitocin -Synthetic formulation (pitocin) -Administered antepartum, intrapartum, and/or postpartum (each has a different protocol!) to cause uterine contractions -Antepartum or Intrapartum - Delivered intravenously by constant infusion pump and carefully titrated to desired effect (milliunits/minute) -Postpartum - Administered intravenously or intramuscularly (10-20 units) after 3rd stage to maintain uterine contraction and achieve hemostasis (slow down blood loss by causing contractions) Black box warning (high doses) can result in uterine rupture if we overstimulate the uterus (antepartum or intrapartum

Regional analgesia Regional anesthesia Local perineal infiltration anesthesia Pudendal nerve block

Regional analgesia: some pain relief and motor block Regional anesthesia: complete pain relief and motor block Local perineal infiltration anesthesia: used for episiotomy Pudendal nerve block: done late in second stage of labor, also useful if an episiotomy is performed or if forceps or a vacuum extractor are used

Risk factors associated with preterm labor? Common indications for preterm birth? Cervical length?

Risk factors for spontaneous preterm labor: -Hx of genital tract colonization, infection, or instrumentation -African American race -Genetics -Bleeding of uncertain origin in pregnancy* -Hx of previous spontaneous preterm birth -Uterine anomaly -Use of assisted reproductive technology -Multifetal gestation -Cigarette smoking, substance abuse -Pregnancy underweight (BMI < 19.6) and pre-pregnancy obesity -Periodontal disease -Limited education and low socioeconomic status -Late entry to prenatal care -High levels of personal stress in one or more domains of life -Social determinants (lack of access to prenatal care, living in a bad neighborhood, being poor.) Common causes of Indicated Preterm birth: -Preexisting or gestational diabetes -Chronic hypertension -Preeclampsia -Obstetrical disorders or risk factors in the current or previous pregnancies (previous cesarean birth via vertical or T shaped incision,) cholestasis, placental disorders.) -Medical disorders (seizures, obesity, smoking, maternal HIV or active herpes, asthma) -Advanced maternal age -Fetal disorders (chronic poor fetal growth, abnormal test results CST, NST) -Polyhydramnios or oligohydramnios -Birth defects -Fetal complications of multifetal gestation (growth deficiency, twin to twin transfer syndrome.) Cervical length: is a possible indicator of preterm labor; women whose cervical length measured via transvaginal ultrasound that is greater than 30 mm in the second and third trimester of pregnancy are unlikely to give birth prematurely even if they have symptoms of premature labor*

Obstetrical Emergencies Rupture of the Uterus Causes? Risk factors? S/S?

Rupture of the Uterus: -Rare, serious obstetric injury; occurs in 1 in 20,000 births -Most frequent causes of uterine rupture during pregnancy: -Separation of scar of a previous classic cesarean birth (repair of uterus was not done effectively or healing was impaired OR very little spacing between pregnancies) (especially with vertical incisions (up and down), we most commonly see a horizonal incision which has a lower risk of rupture—You're cutting with the gain because muscle fibers run that way in the lower segment) -Uterine trauma (e.g., accidents, surgery) -Congenital uterine anomaly -**One of the most preventable causes of uterine rupture is the overuse of exogenous drugs like Pitocin = too many strong uterine contractions cause the rupture. Rupture of the Uterus - Other risk factors During labor and birth: -Intense spontaneous uterine contractions -Labor stimulation (e.g., oxytocin, prostaglandin) -Overdistended uterus (e.g., multifetal gestation) -Malpresentation*, external or internal version -Difficult forceps-assisted birth -Occurs more in multigravidas than primigravidas* (due to difficulty controlling uterine muscle fiber integrity in the multipara) Signs & Symptoms Ruptured Uterus -Abnormal FHR Tracing* -Loss of Fetal Station (moves up)* and uterine tone* (intrauterine pressure of 0) -Constant Abdominal Pain -Uterine Tenderness -Change in Uterine Shape -Cessation of Contractions (intrauterine pressure = 0) Mother S/S: Hypovolemic shock, hemorrhage, (↓BP, tachypnea, pallor, cool, clammy skin)

Obstetric emergencies Rupture of the uterus What is it? Uterine dehiscence? S/S? Care?

Rupture of the Uterus: -Uterine rupture is defined as symptomatic disruption and separation of the layers of the uterus or previous scar. It can result in the ejection of fetal parts or entire fetus into the peritoneal cavity. · Major factor for uterine rupture is a scarred uterus from previous C-section or other uterine surgery. · Rupture most often occurs during a TOL or VBAC. Uterine dehiscence aka incomplete uterine rupture involves a separation of a prior scar. (Does not always result in hemorrhage.) S/S: most common finding is a category II or III FHR tracing, sharp abdominal pain or ripping/tearing sensation not associated with contractions, bright red vaginal bleeding, signs of hypovolemic shock caused by hemorrhage (hypotension and tachypnea) Care: Prevention is the best treatment. We monitor for signs of uterine tachysystole because this can indicate uterine rupture. If tachysystole occurs, we want to decrease or stop infusion of oxytocin. Hysterectomy may be necessary if rupture is large and diffult to repair

Obstetrical Emergencies Shoulder Dystocia What is it? Risk factors? Signs? Sequelae for infant/mother?

Shoulder Dystocia: -Occurs when the anterior shoulder after external rotation impedes against pubic bone. Head is not the largest diameter of the body, shoulders and thorax are (for this case.) Shoulders get stuck in birth due to their positioning Risk Factors: -Macrosomia (fetus that is much larger than average) (thorax diameter is larger than their head circumference. Macrosomia means large body compared to the head) (In non-macrosomia babies, the head is the largest portion of the baby.) -Abnormal labor patterns -Turtle sign at delivery (baby head born by extension and then retracts back down in perineum) Sequelae: -Maternal trauma -Fetal trauma -Fractured/dislocated clavicle -Brachial plexis injury** (temporary or permanent damage) -Asphyxia/neurologic insult

Obstetric emergencies Shoulder Dystocia What is it? Early indicator? Maternal complications? Care/interventions during birth to help?

Shoulder Dystocia: -Uncommon emergency: the head is born but the anterior shoulder cannot pass under the pubic arch. It can occur from size discrepancy between the fetal shoulders and pelvic inlet, fetopelvic disproportion related to excessive fetal size or maternal pelvic abnormalities. Maternal diabetes can cause macrosomia. A long second stage of labor can also cause it to occur Shoulder dystocia cannot be accurately predicted or prevented Turtle sign is an early indicator of shoulder dystocia - retraction of the fetal head against the perineum immediately following its emergency Right arm is usually the one affected Major maternal complication with this is postpartum hemorrhage and rectal injuries* Care: The McRoberts Maneuver and Suprapubic pressure can be done; The woman's legs are hyper-flexed on her abdomen to cause the sacrum to straighten, and the pelvis and symphysis pubis rotate towards the mothers head. The angle of pelvic inclination is decrease which frees the shoulder Suprapubic pressure can then be applied over the anterior shoulder to dislodge it **Fundal pressure to relieve shoulder dystocia should be AVOIDED because it will only further impact the anterior shoulder behind the symphysis pubis The Gaskin maneuver (the woman moves to a hands/knees position) can also be done to relieve shoulder dystocia but may not be possible due to epidurals

Side effects of Neuraxial anesthesia? -Advantages? -Fetal complications are shown through what? -Elevation of temp? -Does epidural/spinal block increase risk of C-section?

Side effects of Neuraxial Anesthesia: -Hypotension* -Local anesthetic toxicity (light headed, dizziness, tinnitus, metallic taste, numbness of the tongue/mouth, bizarre behavior, slurred speech, convulsions, loss of consciousness,) fever, urinary retention, pruritus (itching,) limited movement, longer second stage labor, increased use of oxytocin, increased likelihood forceps or vacuum assisted birth, high or total spinal anesthesia. Several advantages of epidural block in laboring woman: -The most effective form of pain relief is provided -Good relaxation is achieved -Airway reflexes remain intact (compared to general anesthesia.) -Only partial motor paralysis develops Fetal complications of epidural block are rare but are indicated by maternal hypotension* The dose, volume, number of medications used can be modified to allow the woman to push, to assume upright positions, and even to walk. **High spinal or total spinal anesthesia resulting in respiratory arrest can occur if the relatively high dosage used with epidural block is accidently injected in the subarachnoid space (instead of the epidural space)** Elevation of temp (from giving epidural) can cause fetal tachycardia* **Epidural analgesia increases risk of use of oxytocin and forceps or vacuum assisted birth but does not increase risk for Caesarean birth.

Spinal anesthesia (Block) Side effects? Advantages/disadvantages?

Spinal anesthesia (block): an anesthetic solution containing a local anesthetic alone or in combination with an opioid agonist is injected through the third, fourth, or firth lumbar interspace into the subarachnoid space. Side effects: Marked hypotension, impaired placenta perfusion and ineffective breathing pattern may occur during spinal anesthesia** IV fluid preloading may be used to reduce the frequency of maternal hypotension after spinal anesthesia for cesarean birth. *Fluid used for a bolus should NOT contain dextrose; can contribute to neonatal hypoglycemia. After giving the anesthetic, maternal BP, pulse, RR and FHR pattern must be assessed and documented every 5-10 min The advantages of spinal anesthesia include ease of administration and absence of fetal hypoxia with maintenance of maternal BP within a normal range The disadvantages include possible medication reactions, hypotension*, impaired breathing (cardiopulmonary resuscitation may be needed,) an increased risk of episiotomy, forceps assisted birth, or vacuum birth tends to be more likely because the woman's voluntary expulsive efforts are reduced or eliminated.

Spinal block is inserted where? What about an epidural block?

Spinal block = inserted into the subarachnoid space Epidural block = inserted into the epidural space Spinal anesthesia (blocks) and epidurals are done between contractions

Incompetent cervix

Spontaneous, premature dilation of the cervix during the second trimester of pregnancy Treatment is often a cervical cerclage*

What is gate control pain theory? Cutaneous, sensory, and cognitive strategies to control pain?

The spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain Gate-Control Pain Theory says pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations or messages can travel through these nerve pathways at one time. Using distraction techniques reduces or completely blocks these nerve pathways to transmit pain; closing down the hypothetical gate in the spinal cord. -Use massage, aromatherapy, hypnosis, music, and guided imagery -Stimulating the senses will not create a pain free environment but can help reduce the discomforts of labor. The analgesic effect of many nonpharmacologic measures is comparable to or even superior to that of opioids administered parenterally. Cutaneous stimulation strategies: -Counterpressure (Pressure applied by a support person with a firm object (tennis ball, fist, hand,) it lifts the occiput off the spinal nerves that cause the mom back pain) -Effleurage (light massage) (Light stroking, distracts the laboring mom) -Therapeutic touch and massage -Walking -Rocking -Changing positions -Application of heat or cold -Transcutaneous electrical nerve stimulation (TENS) (Low electrical impulses help facilitate the release of endorphins) -Acupuncture (Promotes the circulation of blood) -Water therapy (showers, baths, whirlpool baths) -Intradermal water block (Involves the injection of small amounts of sterile water into four locations on the lower back to relieve lower back pain) Sensory stimulation strategies: -Aromatherapy -Breathing techniques (Slow breathing is good early on in labor, faster breathing when labor becomes more intense. Watch for resp. alkalosis (hyperventilation)) -Music (Provides distraction, enhances relaxation and lifts spirits during labor) -Imagery -Use of focal points Cognitive strategies: -Childbirth education -Hypnosis (Form of deep relaxation like daydreaming or meditation. It's focused concentration where the subconscious mind can me more easily accessed) -Drinking herbal tea

Position woman should be when receiving an epidural/spinal block?

The woman should sit or lie on her side (modified sims position) with her back CURVED to widen the intervertebral space. After the epidural is given, the woman is positioned preferably on her side so the uterus does not compress the great vessels and so hypotension is avoided. Her position should be alternated from side to side every hour.**

Regional opioids for post-operative pain Duramorph

To provide post-operative analgesia for 24-48 hours without affecting sympathetic tone, sensation, and voluntary motor function Duramorph: 2 -5 mg (epidural) 0.1-0.2 mg (spinal) -Side effects include: Pruritus (30%), nausea, sedation, and respiratory depression -Monitor for sedation and respiratory depression for 12 to 18 hours (VS + LOC and 02 sat q hour) Naloxone (0.04mg) IV immediately available Ondansetron 4 mg IV for nausea & vomiting Diphenhydramine 25 to 50 mg IM or IV (itching)

What is a trial of labor? (TOL)

Trial of Labor: the observance of a woman and her fetus for a reasonable period (4-6 hours) of spontaneous active labor to assess the safety of vaginal birth for the mother and infant The most common reason for TOL is if the woman wishes to have a vaginal birth after a previous C-section The woman is evaluated for active labor including adequate contractions, engagement, and descent of the presenting part and effacement and dilation to the cervix.

VBAC (Vaginal birth after C-section) Eligibility? Risks/benefits? Perinatal morbidity/mortality?

Vaginal Birth After Cesarean: -There is a decrease in vaginal birth after having a C-section · Eligibility: -Pt who has low-Transverse uterine scar (horizontal scare) -Indication for prior C/S not prohibitive of future vaginal birth* Risks/Benefits -Success rates - 60-80% (74% NIH, 2010) Perinatal morbidity and mortality -uterine rupture = <1% -associated with prostaglandin and oxytocin use -lower maternal mortality but higher perinatal (fetal/neonatal) mortality compared to ERCS (NIH 2010) -Successful VBAC avoids surgery -The lowest risk for uterine rupture (< .5%) is one prior c/s scar horizontal in lower uterine segment with double layered suture closure, < 30 years of age, > 2 years since surgery, no induction/aumentation of labor -Vertical incision on uterus are not good candidates for VBAC Considerations: -Resource availability · Surgeons/Operating rooms -Patient preference -Institutional policies -Trends (Book) Vaginal Birth after Cesarean: Indications for primary cesarean birth (breech presentation, abnormal FHR) are often non-reoccurring; Therefore, a woman who has had a C-section birth with a low transverse uterine incision may become pregnant again and choose to attempt a VBAC A VBAC is contraindicated for women who are at high risk for uterine rupture, women who had a T shaped uterine incision or extensive trans fundal uterine surgery, who have had a previous uterine rupture -VBAC success rate is 60-80% -< 19-month birth interval and preeclampsia are associated with a reduced chance for a successful VBAC -The major risk associated with VBAC is uterine rupture**

What is "Version" ? (External and internal version)

Version: is the turning of the fetus from one presentation to another External cephalic version (ECV): done to turn the fetus from a breech or shoulder presentation to a vertex presentation using gentle, constant pressure on the abdomen (36-37 weeks.) Informed consent must be obtained and a tocolytic agent is often given to relax the uterus. Internal version: insert hand into uterus and changes presentation to cephalic (head.) Rarely used, done with twin births.

Fetal Fibronectin (fFN) Negative vs positive test?

When women present to their provider with persistent uterine contraction patterns prior to term and minimal to no cervical change, the provider may perform a test for a biochemical marker called fetal fibronectin. This substance is a protein secreted by the fetus in early pregnancy to help adhere the fetal membranes to the walls of the uterus. It is present in maternal cervical secretions up to about 22 weeks gestation and then again at 35 weeks and beyond, when the bonds begin to break down in preparation for labor onset and the protein in again detected in maternal secretions. Between 22 and 35 weeks, however, it is not typical to detect fFN in cervical mucous. For women with questionable PTL, a negative fFN Test assures providers to about a 99% degree of certainty that PTB will not occur within the next 2 weeks. If the test is positive, fFN was detected in higher than expected amounts. While the woman is at higher risk for PTB, the predictability that PTL is occurring is less specific, and this test result cannot give reliable information about when or if PTB will occur. However, based on results provider can initiate closer monitoring and/or treatment for PTL with a positive result and avoid unnecessary treatment for women with a negative result. (Book) Fetal Fibronectin Test: fFN is a glycoprotein "glue" found in plasma and produced during fetal life; found in cervical and vaginal secretions EARLY in pregnancy then again LATE in pregnancy. fFN found in the late second trimester and early third trimester may be related to placenta inflammation which is thought to be a cause of spontaneous preterm labor. -This test is often used to predict who will NOT go into labor because neg predictive value is high (Less than 1% chance of giving birth within the next 2 weeks)

Should women with preterm/prelabor contractions WITHOUT cervical change be given tocolytic medications?

Women with preterm contractions without cervical change (especially with cervical dilation less than 2cm) should NOT be given tocolytic medications (meds that inhibit uterine contractions) Why? -- Because they are not in true labor! There's no cervical change so no reason to stop the contractions?

Epidural vs spinal dose of drugs (amount and duration)

see pic Lower doses for spinal blocks because they work faster (immediately)