High Risk Labor and BirthsChapter 21

Mary L. Dunlap MSN

Fall 2015

Labor and Birth at Risk

Dysfunctional Labor

• Dystocia- abnormal or difficult labor

• Leading indicator for primary cesarean sections in the USA

• Early identification and prompt interventions help to minimize risk to mother and fetus

Dystocia Factors

• Maternal positioning

• Powers

• Passenger

• Passageway

• Maternal stress (psyche)

• Table 21.1 pg 708-714

Maternal positioning

• Can interfere with the decent of the fetus

• Maternal built

• Uterine abnormalities/congenital malformations

Uterine Contractions

Hypertonic

•Uterus never fully relaxes between contractions

•Strong, painful, ineffective contractions

•Contributing factor- maternal anxiety

Management

•Rest, hydration, sedation

Uterine Contractions

Hypotonic •Decrease in frequency and intensityManagement•Ambulation •Position change•Augmentation

Uterine Contractions

Precipitous Labor and Birth

•Rapid intense contractions

•Fetus delivered rapidly (less than 3 hrs.)

Management

•Monitor progression of labor

•Reassure and support patient

•Breathing to avoid pushing and prevent tearing

Passenger

• Persistent occiput posterior position

• Breech presentation

• Shoulder dystocia

• Multiple gestation

• Macrosomia

Passageway

• Contraction of one or more of the three planes of the maternal pelvis: inlet, midpelvis, and outlet

• Obstruction in the birth canal: placenta Previa, uterine fibroids, full bladder and cervical swelling

Maternal Psyche

Emotions

•Fear, Anxiety, Helplessness, Exhaustion and Feeling alone cause psychological stress

Management

•Provide physical and emotional support

•Comfort measures

•Pain management

Preterm Labor and Birth

Preterm labor and birth

• Preterm labor: cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy

• Preterm birth: any birth that occurs before the completion of 37 weeks of pregnancy

Preterm Labor and Birth

Risk Factors

• Infections

• Low Socioeconomic status

• Smoking

• Little or no prenatal care

• Domestic violence

• Box 21.2 pg.722

Preterm Labor and Birth

Predicting preterm labor and birth

• Fetal Fibronectin

• Salivary Estriol

• Transvaginal U.S.

• Home Monitoring

Preterm Labor and Birth

Uterine contractions

• Pattern more frequent than every 10 minutes persisting for 1 hour or more

Discomfort

• Dull, intermittent low back pain

• Menstrual like cramps

Preterm Labor and Birth

• Suprapubic pain or pressure

• Pelvic pressure or heaviness

• Urinary frequency

Vaginal discharge

• Change in discharge

• Rupture of amniotic membranes

Preterm Labor and Birth

Prevention

• Educate woman about early symptoms of preterm labor

• Any symptoms of uterine contractions or cramping between 20 and 37 weeks of gestation that do not go away are not normal discomforts of pregnancy require contacting primary health care provider

Preterm Labor and Birth

Lifestyle modifications

• Activities resulting in preterm labor

Sexual activity

Carrying heavy loads

Standing more than 50% of the time

Heavy housework or climbing stairs

Hard physical work

Being unable to stop and rest when tired

Teaching Guidelines 21.1 pg. 724

Preterm Labor Management

• Bed restCommonly used for prevention of preterm birthNo evidence to support effectiveness in reducing preterm birth rates

• Tocolytics- suppression of uterine activity

• Glucocorticoid to help accelerate fetal lung maturity

Preterm Labor and Birth

Management of inevitable preterm birth

•4cm dilation inevitable preterm birth

•Births in tertiary centers better neonatal and maternal outcomes

•Women at risk improved outcome at tertiary center

•Administer Glucocorticoids before transfer

Prolonged Pregnancy

• Continues beyond 42 weeks gestation

• Risk for fetal/neonatal problems

• Increase risk for cesarean birth due to utero-placental insufficiencies

Post Term Labor and Birth

Maternal risks related to Fetal Macrosomia

• Dystocia of labor

• Infection

• Birth trauma

• Post partum hemorrhage

Post Term Labor and Birth

Fetal Risks

• Asphyxia

• Meconium aspiration

• Hypoglycemia

• Respiratory distress

• Macrosomia- Brachial plexus injuries

• 12310

Post Term Labor and Birth

ManagementManagement

•Induction of labor

•Monitor fetus for signs of uteroplacental insufficiencies

Induction/Augmentation of Labor

• The stimulation of uterine contractions by medical and surgical means to produce delivery before the onset of spontaneous labor.

• Augmentation enhances ineffective contractions after labor has begun

Induction/Augmentation of Labor

Considerations for induction

• Post term

• Prolonged rupture of membranes

• Gestational hypertension

• Preeclampsia

• Diabetes

• Fetal demise

Induction/Augmentation of Labor

Risks

• Cesarean delivery

• Instrumented assisted delivery

• Epidural analgesia

• Fetal stress and admission to neonatal intensive care unit

Induction Contraindications

• Complete Previa

• Abruptio placenta

• Transverse lie

• Prolapsed umbilical cord

• Previous Myomectomy

• Herpes

• Previous C/Sec

Induction/Augmentation of Labor

BishopScore

0 1 2 3

Dilatation 0 1-2 3-4 5 or more

Effacement 0-30% 40-50% 60-70% 80-100%

Station -3 -2 -1 +1 +2

Cervical consistency

Firm Med Soft

Cervixposition

Posterior Mid Anterior

Cervical Ripening Methods

• Nonpharmacologic

• Mechanical

• Surgical

• Pharmacologic

Nonpharmacologic Methods

• Herbal agents

• Castor oil

• Enemas

• Sexual intercourse

• Breast stimulation

Mechanical Method

• Application of Local pressure to the cervix stimulating the release of prostaglandins to ripen the cervix

• Foley catheter inserted into Endocervical canal to ripen & dilate cervix

• Hygroscopic dilators absorb Endocervical & local tissue fluids; as they enlarge they create mechanical pressure (Laminaria)

Surgical Methods

• Stripping of membranes- place a finger through the cervix and move it in a circular direction causing the membranes to detach

• Amniotomy with an Amniohook fetal head now applies pressure to the cervix stimulating increase in prostaglandins

Pharmacological

• Prostaglandins

• Oxytocin

• Drug Guide 21.2 pg.729

Oxytocin (Pitocin)

• Hormone produced by posterior pituitary gland

• Stimulates uterine contractions

• Used to induce labor or to augment a labor progressing slowly because of inadequate uterine contractions

Oxytocin (Pitocin)

• Oxytocin is always administered by infusion pump piggybacked into the main line at the closest port to the insertion site

• Start induction at 1-2 mU/min

• Increase rate q 30-60 min by 1-2mU until a contraction pattern of q 2-3 min lasting for 40 to 60 sec.

Oxytocin (Pitocin)

• Continuous fetal monitor to evaluate contraction pattern and FHR

• Prior to starting induction verify term pregnancy and vertex position

• If Hyperstimulation occurs turn Oxytocin infusion off to let the uterus rest and notify Provider

Premature Rupture of Membranes

Rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of labor at any gestational age

Preterm Premature Rupture of Membranes (PPROM)

• Rupture before 37 weeks gestation

• Occurs in up to 25% of preterm labors

• Often preceded by infection

• Etiology unknown

• Diagnosed after woman complains of sudden gush or slow leak of vaginal fluid

Birth Related Interventions

• Amnioinfusion

• Forceps/Vacuum assisted delivery

• Episiotomy

• Cesarean section

• VBAC

Amnioinfusion

• Warm sterile NS or RL IV solution is infused into the uterus through an intrauterine pressure catheter to increase the amniotic fluid volume

• Cushion the umbilical cord

• To help thin meconium

Amnioinfusion

• Contraindications: vaginal bleeding of unknown origin, umbilical cord prolapse, amnionitis, uterine hypertonicity and sever fetal distress

• Follow hospital policy for infusion

• Complications: abruption, cord prolapse, fetal hypothermia

Forceps-Vacuum Assisted Birth

• Prolonged second stage

• Fetal distress

• Abnormal presentations

• Arrest of rotation

• Delivery of head in a breech presentation

Forceps

Birth Related Interventions

Vacuum-assisted

• Vacuum applied to fetal head, negative pressure to assist birth of head

–Prerequisites

• Vertex presentation

• Ruptured membranes

• Absence of CPD

Episiotomy

• Incision made in the perineum to enlarge the vaginal outlet

• Locations- midline, R or L Mediolateral

• Alternative measures- warm compresses, massage with oil have been successful in stretching perineal area

Cesarean Birth

• The delivery of the fetus through an incision in the abdomen and uterus

• Classical

• Low Transverse

• USA 1 in 3 births

Cesarean Birth indications

• Recognition of fetal distress due to Electronic fetal monitoring

• Preserve life of mother and fetus

• Failed labor

• Failed VBAC

Cesarean BirthComplications and Risks

• Anesthesia

• Surgical complications

• Impaired bonding

• Post partum complications

Cesarean Birth

• Preoperative care

• Intraoperative care

• Immediate postoperative care

• Postpartum care

Cesarean Birth

• Cesarean Birth

Vaginal delivery after a Cesarean (VBAC)

• A woman who has had a previous cesarean and gives birth vaginally after at least one previous cesarean birth.

• Controversial choice

• Risk for uterine rupture, hemorrhage and fetal mortality

VBACContraindications

•Prior classic uterine incision

•Uterine scar other than a low transverse

•Prior transfundal uterine surgery

•Inadequate staff or facility

•Use of cervical ripening agents

VBAC

• Special areas of focus: consent, documentation, surveillance, and readiness for emergency

• Nursing care is focused FHR tracing to identify nonreassuring pattern and instituting measures for emergency delivery

Obstetric Emergencies

• Umbilical cord prolapse

• Placenta Previa

• Placental abruption

• Uterine rupture

• Shoulder Dystocia

• Fetal Demise

Cord Prolapse

Lies below presenting part of fetus

Contributing factors

•Long cord (longer than 100 cm)

•Malpresentation (breech)

•Transverse lie

•Unengaged presenting part

•Hydramnios

Cord Prolapse

Cord Prolapse

Management

•Hold the presenting part off the umbilical cord until delivery

•Change patients position to relieve cord pressure

•Monitor fetal heart rate

•Emotional support

•Pre-per for c/sec

Cord Prolapse

Cord Prolapse

Placenta Previa

• Placental implantation in the lower uterine segment

• Position can create a barrier for vaginal delivery of the fetus

Placental Abruption

• Premature separation of placenta

Management

• Based on gestational age, extent of hemorrhage and maternal-fetal oxygenation perfusion

• Maintain maternal cardiovascular status

• Prompt delivery

• Cesarean birth if fetus still alive; vaginal birth if fetal demise

Uterine Rupture

• Uterine tearing at the site of a previous scar.

Causes

• Uterine trauma: accidents, surgery

• Congenital uterine anomaly

• Intense uterine contractions

Uterine Rupture

Causes• Labor stimulation• Over distended uterus• Malpresentation: external or internal

version• Difficult forceps-assisted birth• More often in Multigravidas

Uterine Rupture

• Management

• Pre pare mother for Stat emergency C/sec

• Administer IV fluid & blood to combat hemorrhage

• O2 to help with fetal compromised

• Mother will be anxious stay calm

Shoulder Dystocia• Head is born, anterior shoulder

cannot pass under pubic arch

• Delivery can cause newborn birth injuries

• Maternal risk: excessive blood loss, lacerations, extension of episiotomy, or Endometritis

Shoulder Dystocia

Management

•McRoberts maneuver

•Suprapubic pressure

Shoulder Dystocia

• Shoulder Dystocia simulation

• Shoulder Dystocia delivery