Reproduction: Intrapartum Labor at Risk

dystocia

anything that alters labor (took quick or prolonged)

-problems with powers (hypertonic, hypotonic uterine dysfunction and precipitate labor)

• ideally want 2-3 contractions within 10 min period

-arrest in dilation: cervix doesn’t continue to dilate

-problems with passenger (fetal position)

-protracted disorders

-problems with psyche

dystocia risk factors

-epidural analgesia/excessive analgesia (can slow down the process of labor)

-multiple gestation

-hydramnios

-maternal exhaustion, ineffective maternal pushing technique

-occiput posterior position (causes a lot of pain)

-high fetal station at complete cervical dilation

-long first stage of labor

-nulliparity, short maternal stature

-fetal birth weight over 8.8lb

-previous shoulder dystocia

-fetal anomalies, overweight, gestational age >41wks

dystocia assessment

-hx of risk factors

-maternal frame of mind (psyche)

-vital signs

-bladder (can cause irritability on contraction tracing and puts pressure on fetus)

-uterine contractions (powers)

-fetal heart rate, fetal position (passenger)

-assess passageway

dystocia nursing management

-promoting labor progress

-providing physical and emotional comfort

-promoting empowerment

shoulder dystocia

obstruction of fetal descent and birth by axis of the shoulders once the head is delivered

-primary reason is large infant (macrosomia)

-can result in permanent brachial plexus

-obstetric emergency

-McRobert’s position: lower the head and put mother’s legs all the way back

-apply suprapubic pressure

-fetus goes into respiratory distress

-in severe care, can break the fetus shoulder

-episiotomy can be performed

preterm labor

regular uterine contractions with cervical effacement and dilation between 20 and before 37 wks gestation

preterm labor management

-risk prediction (organ immaturity, bonding, thermoregulation)

-tocolytic drug: there are no clear first-line drugs to manage preterm labor: may prolong pregnancy for 2-7 days while steroids can be given or fetal lung maturity

-meds:

• betamethasone: lung maturity, give 2 doses 24 hrs apart

• magnesium sulfate (CNS depression)

• antibiotic prophylaxis for women with GBS

• nifedipine (CCB)

  • indomethacin

preterm labor assessment

-risk factors

-subtle signs of contraction pattern (4 contractions every 20 min or 8 contractions in 1 hr)

preterm labor labs

-CBC

-amniotic fluid analysis (PPROM)

-fetal fibronectin

-cervical length via transvaginal ultrasound

-home uterine activity monitoring

preterm labor education

-come to hospita if:

• bleeding

• contractions increase

• abdominal pain

• fetal movement (minimal or none)

• rupture of membranes

-no intercourse

postterm labor

pregnancy continuing past end of 42wks gestation

-unknown etiology

-oxygen begins to decrease in the placenta, causing fetal hypoxia

-after 40wks gestation, pt comes in 2x/wk for testing

-monitor fetal movement

postterm labor maternal risks

-cesarean birth

-dystocia

-birth trauma

-postpartum hemorrhage

-infection

-oligohydramnios

postterm labor fetal risks

-macrosomia

-shoulder dystocia

-brachial plexus injuries

-low Apgar scores

-post maturity syndrome

-cephalopelvic disproportion

-meconium as a result of hypoxia

postterm labor assessment

-estimated DOB

-daily fetal movement counts

-nonstress 2x/wk

-amniotic fluid analysis

-weekly cervical exams

-client understanding

-anxiety

-coping ability

postterm labor nursing management

-fetal surveillance

-decision for labor induction

-support

-intrapartum care

-education

induction

stimulating contractions via medical or surgical means

augmentation

enhancing ineffective contractions after labor has begun

induction and augmentation indication

-prolonged gestation

-PROM/PPROM

-gestational HTN (nifedipine, magnesium sulfate, labetalol, lasix, hydralazine)

-cardiac disease

-renal disease

-chorioamnionitis

-dystocia

-intrauterine fetal demise

-isoimmunization

-diabetes

induction and augmentation contraindications

-cephalopelvic disproportion

-abnormal fetal presentations (breech or transverse)

induction and augmentation management

-continuous FHR monitoring

-cervical ripening herbal agents

-castor oil, hot baths, enemas

-sexual intercourse with breast stimulation

-mechanical methods: dilators, foley balloon

-surgical methods: amniotomy (AROM) to help break pt’s water

-dinoprosterone (cervidil insert, preppidil gel), misoprostol (cytotec)

-pitocin

bishop score

score of 8+ is favorable to be induced

-provider calculates score

-score of 5 or less pt will be told to go home

VBAC

vaginal birth after a cesarean

-first TOLAC to be successful with a VBAC

-identify risk factors

• can’t be high risk (HTN, active infection, etc)

-contraindications:

• large birth weight

• -infection

• 3+ c-sections

-readiness for emergency (risk for uterine rupture)

uterine rupture

onset marked by sudden fetal bradycardia and variable decelerations, severe abdominal pain

-obstetric emergency

-onset of sudden fetal distress and loss of fetal station

-can lead to fetal demise

-prep for urgent c-section

-continuous maternal and fetal monitoring

-pt that has had multiple c-sections are at a higher risk

-recommended for pt not to have children anymore

intrauterine fetal demise (IUFD)

-causes:

• advanced maternal age (40+yrs)

• postterm pregnancy

• substance abuse

• blunt trauma

• smoking

• renal disease

-occurs after 20wks gestation

IUFD assessment

-inability to obtain FHR on EFM

-ultrasound to confirm absence of fetal activity (provider confirms)

-labor induction

IUFD management

-assistance with grieving process and provide support: sadness, despair, confusion

-if pt is bleeding after 7 days of birth of fetus, pt is at risk for DIC and PE
-products of conception are removed

-referrals

umbilical cord prolapse

-obstetric emergency

-partial or total occlusion of cord with rapid fetal deterioration

-continuous assessment of client and fetus

-prompt recognition

umbilical cord prolapse management

-change positions to modified sims, trendelenburg, or knee chest position to relieve pressure

-do not push cord in

-relieve any presenting part off of the cord

-rushed to the OR

amniotic fluid embolism (AFE)

-obstetric emergency

-sudden onset of hypotension, hypoxia, and coagulopathy due to breakage in barrier between maternal circulation and amniotic fluid

AFE assessment

-dyspnea

-hypotension

-cyanosis

-seizures

-tachycardia

-coagulation failure

-DIC

-pulmonary edema

-uterine atony with subsequent hemorrhage

-ARDS

-cardiac arrest

AFE management

-supportive measures to maintain oxygenation and hemodynamic function to correct coagulopathy

-critical care monitoring

amnioinfusion

-indications:

• severe variable deceleration due to cord compression

• oligohydramnios due to placental insufficiency

• postmaturity or rupture of membranes

• preterm labor with premature rupture of membranes

• thick meconium fluid

-management:

• teaching

• fetal and maternal assessment

  • prep for possible c-section

forceps or vacuum-assisted birth/delivery

-application of traction to fetal head

-indications:

• prolonged 2nd stage of labor

• nonreassuring FHR pattern

• failure of presenting part to fully rotate and descend

• limited sensation or inability to push effectively

• presumed fetal jeopardy or fetal distress

• maternal heart disease

• acute pulmonary edema

• intrapartum infection

• maternal fatigue

• infection

-pt is fully dilated and fetus is engaged

-risk of tissue trauma to mother and newborn, head or face laceration

cesarean birth

-indicated for pt who can’t have a vaginal birth, emergency situation

-classic or low transverse incision

-assessment: hx and physical exam of mother and fetus

cesarean birth management

-pre-op care:

• prior c-section and outcome

• anesthesia reactions

• antibiotics

• GI prep

• explain recovery process

• may not be able to do skin-to-skin

• bottle feeding

-post-op care:

• surgical site care to decrease risk of infection