Not done Week 8: Intrapartum complications

Causes of preterm labor and birth (8)

• History of preterm birth

• Bacterial vaginosis

• Intra-amniotic infection

• Intra-uterine inflammation

• PROM

• Multiple gestation

• Bleeding

• Uterine/cervical abnormalities

Preterm labor and birth: signs and symptoms

• Uterine activity

  • Back pain, indigestion (hard to ID that it’s not normal preg s/s)

• Discomfort

• Vaginal discharge

Preterm labor and birth: biochemical markers

• Fetal fibronectin (FFN)

• Endocervical length

Fetal Fibronectin test

speculum exam to determine the likelihood of the woman having preterm labor

• Positive FFN = treat her as if in preterm labor

• Negative = likely not gonna go into preterm labor

Endocervical length exam

the measurement of the cervical effacement to assess the risk of premature birth

• want lack of effacement

• should be >25 mm — any less indicates increased chances of preterm labor

FFN negative: home care

• Education — prevention is key!

• Assessments — home TOCO that is transmitted to provider’s office

• Interventions — progesterone supplementation in women with history

FFN positive: hospital care

Start interventions immediately

• Medications — tocolytics and steroids

• Preterm birth

Tocolysic medication purpose

meds to stop contractions

Tocolytic medication types (4)

• Terbutaline

• Magnesium Sulfate (MgSO4)

• Nifedipine

• Indomethacin

Terbutaline

a smooth muscle relaxant that slows and decreases contractions

• good to treat tachysystole

Terbutaline adverse reactions (7)

• Maternal and fetal tachycardia

• Tremors

• Hyperglycemia

• Possible chest pain

• Dysrhythmias

• Hypotension

• Pulmonary edema

What can be given to reverse cardiac symptoms of terbutaline?

propranolol

Why is terbutaline used for preterm birth if it has so many side effects and isn’t usually recommended?

it is used when they are in a community health office to slow contractions and get mom to hospital with a NICU

• community hospitals often don’t have MgSO4, which is the first choice for preterm labor

What is the drug of choice for preterm labor?

Magnesium sulfate (MgSO4)

Magnesium Sulfate purpose in preterm labor

Neuroprotection and prevention of cerebral palsy

MgSO4 administration route

IV

MgSO4 adverse reactions

• Flushing

• N/V

• Drowsiness

• HA

• Respiratory depression possible

MgSO4 serum therapeutic levels

4-7.5 mEq/L

What test must be done every hour when administering MgSO4?

Patellar deep tendon reflexes

What should patellar DTRs be? What does it mean if they are lower?

• Should be +2

• +1 = diminished

• 0 = absent

• 0 or +1 = mag toxicity!

If a woman has mag toxicity, what should be done immediately?

1. Shut off magnesium sulfate

2. Administer calcium gluconate as the antidote

Nifedipine

PO HTN CCB medication used to help decrease uterine contractions

• do not use with MgSO4 or immediately after terbutaline

Indomethacin

NSAID used as a tocolytic to inhibit uterine contractions and delay preterm labor for up to 48 hours

• used at <32 weeks gestation

Betamethasone

corticosteroid given to mothers in preterm labor to accelerate fetal lung maturity by stimulating surfactant production

Bethamethasone administration method and weeks of gestation

given IM to mother between 24-34 weeks gestation

• EXTREMELY painful

Betamethasone dosing

2 doses over 24 hrs

Beta Complete

24 hours after last betamethadone dose

How long after Betamethasone treatment can it be repeated if delivery hasn’t occurred?

2 weeks

How long does delivery need to be delayed after Betamethasone administration?

Delayed at least 24 hours

Neonatal risks of preterm labor and delivery

• Low birth weight

• Respiratory Distress Syndrome

• Infection

• Birth Injury

• Asphyxia

• Hyperbilirubinemia

Premature Rupture of Membranes (PROM)

ROM at least 1 hour before onset of labor at any gestation

Preterm PROM (PPROM)

PROM before 37 weeks gestation

Risks associated with of PPROM

• Maternal and fetal infections

• Low birth weight

• Cord prolapse

Prolonged ROM

ROM more than 24 hours before birth

Diagnosing PROM

• Ferning (under microscope)

• Pooling (speculum)

• Nitrazine (pH)

Care of patients with PROM COME BACK TO THIS SLIDE!!!!!!!!

Precipitous labor

< 3 hours from first contraction to birth

Precipitous labor: maternal risks

• Uterine rupture

• Postpartum hemorrhage

• Amniotic fluid embolism

• Tears

Precipitous labor: infant risks

• Decreased oxygen — baby not getting adequate rest btwn contractions

• Intracranial hemorrhage

• Facial bruising

Dystocia

Slow or difficult labor that characterized by obstructed labor where the fetus cannot descend through the birth canal

Dysfunctional labor

not dilating 1 cm/hr

Hypertonic Uterine Dysfunction

the uterus has too much tone d/t lots of contractions, but no changes in cervix

Hypertonic Uterine Dysfunction treatment

give morphine

• contractions will stop being hypertonic or will go away completely

Hypotonic Uterine Dysfunction

contractions aren’t strong enough

Hypotonic Uterine Dysfunction treatment

pitocin

Secondary Powers dystocia

mom doesn’t have any more energy to push — Dr. will do a forceps or vacuum assist

Pelvic Dystocia

the birth canal is too small or shaped incorrectly to allow the fetus to pass through

Soft Tissue Dystocia

Obstruction of labor caused by maternal soft tissues (e.g., cervix or vagina) that prevents normal cervical dilation and fetal descent

Fetal dystocia

baby won’t fit through because of the baby’s head shape

Multifetal pregnancy maternal risks

• HTN

• Diabetes

• PPROM

• Preterm labor

• C-section

Multifetal pregnancy fetal risks

• Anomalies

• Preterm birth

• Growth restiction

• Twin-to-twin transfusion

• Entanglement

Multifetal pregnancy: vaginal delivery indications

• Twin A (closest to cervix) is vertex and same or larger than twin B

• They are larger that 32 weeks and 2000 grams

Multifetal pregnancy: nursing responsibilities (2)

• Monitor both twins

• Coordinate plans for 2 neonatal teams and cesarean backup

Breech 3 scenarios — come back!!!!!!

Obesity

BMI >30 kg/m²

Morbid obesity

BMI >40 kg/m²

Obesity complications with pregnancy

• DVT

• C-section

• Emergency C-section

• Wound infection

Bishop score

pre-labor scoring system (0–13) used to predict the success of labor induction by assessing cervical ripeness

• >9 indicates the cervix will be responsive to Pitocin

Parts of the Bishop score

• Dilation

• Effacement

• Station

• Cervical consistency

• Cervical position

Augmentation

stimulating the uterus to increase the frequency, intensity, or duration of contractions to stimulate labor

Cervical ripening

process of softening, thinning (effacement), and opening the cervix, preparing it for labor

Cervical ripening methods

• Chemical

• Mechanical

• Chemical: Prostaglandins

• Mechanical: Balloon

Balloon cervical ripening COME BACK!!! REVIEW VIDEO AT SLIDE 27

Amniotomy

artificial ROM using an amnihook

• can only do this at 0 station

Labor induction COME BACK!!! REVIEW VIDEO AT SLIDE 29

Labor induction indications (4)

• Postdate pregnancy

• IUGR

• PROM with infection

• Maternal health risks

Labor induction contraindications

• Known cephalopelvic disproportion (CPD) — contact provider

• Floating fetal head

• Malpresentation

• Placenta prevailed

• Previous vertical uterine incision

Forceps delivery

• used to deliver fetal head

• fetus must be OA and cannot have cephalopelvic disproportion

Forceps delivery risks

• Fetal skull/neck injury

• Maternal lacerations

• Hematoma

Vacuum assisted delivery

• benefit over forceps

• possible problems

• thought to be less traumatic to fetus because suction is applied rather than pulling on head

• baby scalp injury or hematoma is possible

You can only attach the vacuum seal __ times and can only reattach __ times

• 3 times

• 2 times

C-section indications

• Prior c/s

• Scheduled c/s

• Fetal distress

Bicitra

given before c/s to neutralize gastric acid

Foley catheter purpose during c/s

bladder must be empty when doing a c/s

Post-op care for c/s

• In PACU

  • VS q15 mins

  • Temp q1 hr

  • O2 stat q1 hr

• Assess uterus and bleeding

• Help splint incision

Vaginal Birth After Cesarean (VBAC)

when a woman gives birth vaginally after having a previous c/s

VBAC risk

uterine rupture

• d/t previous surgery making the uterine tissue vulnerable to tearing

VBAC contraindication

women with previous vertical incisions