NRSE360 EXAM#2 complications of labor and birth

Preterm Labor and Birth:

• Preterm labor (PTL): Labor < 37 wks

• Preterm birth (PTB): Gest. age at birth < 37 wks

preterm infant

•  Born after 20 weeks, before 37 wks

Preterm labor: nursing assessment:

• Risk factors Subtle signs

• Contraction pattern

• Laboratory and diagnostic testing: CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length via transvaginal ultrasound, salivary estriol, home uterine activity monitoring

contraction pattern of labor

4 contractions every 20 minutes or 8 contractions in 1 hour

preterm labor

• Regular uterine contractions with cervical effacement and dilation between 20 and 37 weeks’ gestation

• Most common obstetric complications

therapeutic management

• Risk prediction

• Tocolytic drugs

• Antibiotic prophylaxis for women with group B streptococcus

tocolytic drugs

• drugs used to suppress or delay uterine contractions and temporarily pause preterm labor for 24 to 48 hours

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

risk for preterm labor

• #1 is previous preterm labor 

• Infections, HX miscarriage and abortions, multifetal pregnancy, <17 y/o, >35 y/o, smoking, substance use, lack of prenatal care, uterine abnormalities

preterm labor: expected findings

• uterine contractions (more than 4 in an hour)

• pressure in pelvis, low back pain, GI cramping, urinary frequency, vaginal discharge 

preterm labor: assessment finding

•  increase/ change in odor or blood in vaginal discharge, change in cervical dilation, regular contractions, premature ROM

preterm labor labs

•  fetal fibronectin, cervical cultures, CBC, urinalysis 

Diagnostic for preterm labor: Swab of vaginal secretions for FFN 24-34 wks gest

Protein found in vaginal secretions and can be related to inflammation of the placenta that can lead to PTL

• Negative result is good and means they are going to deliver within 10-14 days

Diagnostic procedures: preterm labor

• Measure endocervical length with USN to assess for shortened cervix

• Home uterine activity monitoring

• Cervical cultures to detect presence of infection

• Nonstress test, Biophysical profile

Fetal Bibronectin Test (FFT)

Prediction of PTL: Fetal fibronectin (done btwn 22-35 weeks of pregnancy)

• Negative result/woman not likely to deliver in 10-14 days

• Positive result: protein is leaking, increased PTL risk

What is fetal fibronectin?

• Extracellular protein, “Glue” that attaches fetal membranes to the uterus.

Care for Preterm Labor:

• Focus on stopping contractions

• Modified bedrest

• Left lateral position

• Pelvic rest

• Ensure hydration

What does dehydration cause in mothers experiencing preterm labor

dehydration can cause contractions 

• Dehydration causes brain to release Oxytocin & Anti diuretic Hormone, Oxytocin stimulates contractions

• Monitor VS, Report any s/s of infection

 Fetal tachycardia (>160, prolonged) can indicate

 infection, frequently associated with PTL

Nifedipine

Ca channel blocker

• Monitor for headache, flushing, dizziness & nausea, once stable they can stay on it for a long time (PO med) 

• For preterm labor, preeclampsia 

• Nifedipine should not be given with MGSO4

• Respiratory depression RR<12

magnesium sulfate

Given for neonatal neuroprotection, preterm labor, prevent seizures

• Tocolytic, relaxes smooth muscle of uterus, suppresses contractions

• Instruct client to notify RN of distress (blurred vision, headache, nausea, vomiting, difficulty breathing)

magnesium sulfate (toxicity)

• Monitor for s/s of Mag. Tox. (loss of DTRs, urinary output < 30 cc/hr, respiratory depression, pulmonary edema, chest pain)

• Administer Calcium Gluconate as an antidote as needed 

terbutaline

Beta Adrenergic Agonist SC q 4 hr up to 24 hrs

• Relaxes smooth muscle & inhibits uterine activity

• Do NOT give with hx of Diabetes/Prediabetes, Cardiac Disease, Hypertensive Disorders of pregnancy, Hyperthyroidism & Hemorrhage

• Notify provider with HR >130, BP < 90/60 or any cardiac concerns

• Discontinue if not tolerated by client

Betamethasone

• Glucocorticoid, IM x 2, q 24 hrs, to enhance fetal lung maturity & surfactant production, 24-34 wks gest.

• Monitor for fetal & neonatal: pulmonary edema (chest pain, SOB, crackles), hyperglycemia, heart rate changes

• Psychological support is essential

Preterm labor ROM, preterm pre-labor ROM: risk factors

•  infection, prior PTL, short cervix, 2nd/3rd trimester bleeding, pulmonary or CT disorders, low BMI, tobacco, substance use, risk for cord prolapse

Preterm labor ROM, preterm pre-labor ROM: expected findings

• Fluid leaking from vagina, Variable decels, extended decels, Positive Nitrazine test, GBS cultures, Assess VS, limit vag. Exams, Daily kick counts & BR with BRP

Preterm labor ROM, preterm pre-labor ROM: meds

Ampicillin to rx chorioamnionitis & Betamethasone to promote fetal lung maturity

Post- term pregnancy: assessment and management

• Nursing Assessment: estimated date of birth; daily fetal movement counts, nonstress tests twice weekly, amniotic fluid analysis, weekly cervical examinations, client understanding, anxiety, and coping ability

• Nursing Management: fetal surveillance; decision for labor induction; support; education, intrapartum care

postterm labor timeline

Pregnancy continuing past end of 42 weeks’ gestation

postterm labor: maternal risks

• Cesarean birth, dystocia, birth trauma, postpartum hemorrhage and infection.

• unknown etiology

postterm labor: fetal risks

• macrosomnia (large baby) shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, and cephalopelvic disproportion (head to big, pelvis too small)

• Apgar scores done after birth 

Precipitous Labor:

very quick

• Labor that lasts less than 3 hours from onset of labor to birth

Precipitous Labor: risk factors

• Multips, past precipitous birth

Precipitous Labor: assessment findings

•  Rapid cervical dilation, hypertonic UCs, Potential Category II-III FHR

Precipitous Labor: nursing action

• Prepare for delivery, Stay with pt/family, Monitor FHR/Ucs q 15 minutes, SVEs, Anticipate emergencies (PPH, lacerations, Neonatal hypoxia, CNS depression d/t rapid birth)

turtle sign

 when the baby's head comes out and then goes back in

• Sign of shoulder dystocia

McRoberts Maneuver

knees flexed all the way to chest and then extend (dislodges shoulder

• Superpubic pressure is also applied 

Obstetrical emergency: shoulder dystocia

• Shoulder dystocia refers to difficulty encountered during delivery of the shoulders after the birth of the head.

Obstetrical emergency: risk factors

• Fetal macrosomia, Maternal Diabetes, History of shoulder dystocia, prolonged second stage, excessive weight gain

Obstetrical emergency: associated risks

Fetal injury & death, brachial plexus injury, fractured clavicle (sometimes done on purpose), Maternal complications- Lacerations, infection, hemorrhage

Obstetrical emergency: assessment finding

delay in delivery of shoulders, Retraction of head against maternal perineum after delivery of head (“Turtle sign”)

medical management: shoulder dystocia

• Downward traction may be applied to fetal head with suprapubic pressure

• Extended midline episiotomy 

• McRoberts maneuver, Woods corkscrew maneuver

• Nursing: Education, support, assessment, collaboration & team work

McRoberts maneuver

•  sharply flex thigh onto maternal abdomen then extend

woods corkscrew maneuver

Woods progressively rotates the post shoulder 180 degrees to disimpact the ant shoulder

What do you specifically not do during shoulder dystocia

NO fundal pressure

Tachysystole

 too many contractions, defined as

• Five or more UCs in 10 minutes over 30-minute window

• Series of single UCs lasting 2 minutes or longer

• UCs occurring within 1 minute of each other

Hypotonic Uterine Dysfunction:

• Uterine contractions are either too uncoordinated or too weak to effectively dilate the cervix. Too many contractions 

Hypotonic Uterine Dysfunction: timing/ treatment

• Uterine contractions palpate soft and occur at a rate of less than three or four every 10 minutes lasting less than 50 seconds

• Treatment may include rest, an amniotomy, or oxytocin administration 

induction of labor

• Deliberate initiation of uterine contractions to stimulate labor before spontaneous onset 

induction of labor: indications

• Postdates (book says >42 weeks, its 41 weeks in practice)

• Prolonged premature rupture of membranes (PROM)

• Oligohydramnios: not enough fluid 

• insufficient or low amniotic fluid level. Causes: something wrong with fetal kidneys, or uteroplacental insufficiency, or there was a silent rupture of membranes.

• FGR: fetal growth restriction (baby's is not growing)

• Expectant medical conditions (pre-e, GDM, cholestasis, AMA)

• Fetal demise, Chorioamnionitis, Elective

cervical ripening methods: chemical agents

• Prostaglandin E2 Gel or Prostaglandin E1 (Misoprostol (Cytotec)

cervical ripening methods: mechanical and physical methods

• balloon dilators or amniotic stripping

• Alternative methods

cervical ripening methods: ROM can cause cord prolapse

after ROM immediately check fetal heartrate 

• Amniotomy: priorities; check FHTs before/during/after procedure

oxytocin

• Hormone normally produced by the posterior pituitary gland, which stimulates uterine contractions and aids in milk let-down 

synthetic oxytocin

Pitocin

• may be used either to induce labor or to augment labor that is progressing slowly because of inadequate uterine contractions. 

While on oxytocin watch

Watch for contractions that are too strong or last longer than  90 seconds and are more frequent than every 2-3 minutes  tachysystole (more than 5 contractions in a 10 minute period)

Pitocin

• Pitocin or oxytocin is a synthetic form of a naturally occurring hormone in the body that stimulates uterine contractions. 

• It is an IV drip that gets titrated based on contraction and FHR pattern.

• Normal dosage 1-2 milliunits/min to be titrated up by 1-2 milliunits/min every 20-30 minutes until adequate contractions. 

Pitocin: when to discontinue

• Pitocin can be quickly discontinued for fetal or uterine distress (contractions lasting greater than 90 min or that are closer than 2 minutes apart- uterine tachysystole)

• Can be an induction method for someone who had a c-section in previous delivery

Foley or Cook’s Catheter induction

• A mechanical method of dilation. Cath inserted up into the uterus through the cervix (has to be slightly dilated), the balloon is filed with saline. 

• The pressure of the balloon on the cervix causes manual dilation. Usually used at the same time with low dose Pitocin drip.

• Can be used with someone with previous c-section 

Augmentation of labor: Amniotomy priorities/safety/ nursing responsibilities:

• Ensure presenting part is fully engaged into the pelvis to avoid cord prolapse

• Monitor FHR

• Assess and document characteristics of amniotic fluid- color, odor, amount, and consistency

• Document time of artificial rupture of membranes

• Monitor temperature q2 hours (high risk for infection)

• Comfort measures- frequent pericare and linen changes

Trial of Labor After cesarean (TOLAC)

• Anyone with a prior cesarean section is at risk: Uterine rupture

• Consent needed

• If an induction; only certain methods may be used: Pitocin, Mechanical induction, NO CERVICAL RIPENING AGENTS

• Must have IV and continual fetal monitoring throughout labor!

Vaginal Birth After Cesarean Birth (VBAC):

• HX c-section in the past, there is always a risk for another c-section

• If the person wants to try for a vaginal delivery then they will have a trial of labor after c-section (TOLAC)

• If they show any signs of a possible uterine rupture, then we will rush back for a c-section.

Labor Complications: fetal distress

• Non-reassuring fetal heart tones despite interventions]

• Decision for Cesarean delivery needed within 5 minutes

• Persistent Category II strip despite uterine resuscitation or Category III strip

variable decelerations possible treatment:

amnioinfusion

• Nursing Management: teaching, maternal and fetal assessment, preparation for possible cesarean birth

variable decelerations possible treatment: indications

• Severe variable decelerations due to cord compression

• Oligohydramnios due to placental insufficiency

• Postmaturity or rupture of membranes

• Preterm labor with premature rupture of membranes

• Thick meconium fluid

Meconium Stained Fluid:

• Baby passed stool in utero, high risk for meconium aspiration syndrome in neonate

Major placental abruption or Uterine Rupture:

•  Placenta sheers off the wall of the uterus or Uterus bursts open, chance for hemodynamic collapse and fetal distress/mortality- complications (DIC)

Amniotic Fluid Embolism (anaphylactoid syndrome of pregnancy)

• Very Rare, An emboli of amniotic fluid in expectant circulation, followed by resp distress, coagulation failure,  circulatory collapse Mortality rate ~ 60%

Uterine Rupture cause

Very serious obstetric injury 

• Most frequent cause: Scarred uterus as a result of previous cesarean births, Signs and symptoms, Abnormal FHR tracing w/ sudden bradycardia, Loss of fetal station, Abdominal pain, Shock

Uterine Rupture (nursing assessment/ management)

• Nursing assessment: Risk factors, Onset of sudden fetal distress; other signs 

• Nursing management: Preparation for urgent cesarean birth, Continuous maternal and fetal monitoring

AFE- Definition 

• Amniotic fluid containing particles of debris 

• Acute onset of hypotension, hypoxia, cardiovascular collapse, and coagulopathy

• Maternal mortality to 61% or higher

• Neonatal outcome is poor

AFE (nursing assessment/ management)

• Nursing assessment: difficulty breathing, hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony with subsequent hemorrhage, ARDS, cardiac arrest

• Nursing management: supportive measures to maintain oxygenation and hemodynamic function and to correct coagulopathy; critical care monitoring