labour at risk

complications during labour

• increases chances of mother and baby dead

• may be excepted or happen unexpectedly

what does caring for high risk clients

• understand the normal birth process

• prevent and detect deviations from north labour and birth 

• implement nursing measures if complications arise

what happens in preterm labour

• cervical changes with uterine contractions occuring between 20-37 weeks

which age group has higher risk of preterm labour

• pt. younger than 18 

  • younger adolescents still developing and premature

• pt older than 35

  • elasticity of collagen impacts cervical dilation and cervix opens too early

    • prevent this by cervical curettage

what is preterm birth?

• any birth occuring before 37 weeks completion of pregnancy regardless of weight

what are some risk factors

• history of previous spontaneous preterm birth between 16 and 36 weeks of gestation

• family history of preterm labour

• africian descent

• genitial tract infection

• uterine anomaly

  • womens uterus develops abnormally at birth

• use of assisted human reproduction

• cigar smoking, substance misuse

• peridontal disease

  • gum infection

• bleeding of uncertain origin in pregnancy

• low prepregnancy weight

• low socioeconomic status

• lack of access to prenatal care

• high levels of personal stress in one or more domains in life

what causes preterm labour?

• infections

• vaginal bleeding

• hormone changes

• stretching of the uterus 

signs and symptoms of preterm labour?

• uterine activity

• discomfort 

• vaginal discharge

what does uterine activity refer to

• contractions more often than every 10 mins, lasting an hour

• painful or painless

what type of discomfort

• Lower abdominal cramping similar to gas pains; may be accompanied by

  diarrhea

  • dull, intermittent low back pain 

  • painful, menstrual like cramps

  • suprapubic (lower part of belly) pain or pressure 

what changes do you see in vaginal discharge 

• any change in vaginal discharge

  • thicker and thinner

  • bloody, brown, clear, watery

  • unusual smell

  • come in larger amount than usual

how to predict preterm labour and birth

• fetal fibronectin test

• cervical length less than 30mm risk for preterm labour

• combination of both better

what are the three main signs used to diagnose preterm labour?

• gestational age between 20 and 36 6/7 weeks 

• regular contractions with cervical change 

• regular contractions and cervical dilation of 2cm or greater

what is the main goal of nursing care for preterm labour

• prevention from starting labour too early 

what is preconception counselling ?

• talking to women before pregnancy about ways to stay healthy and lower the risk of preterm birth.

what should be done during prenatal care to prevent preterm labour

• Manage risk factors (like infections, alcohol smoking, stress).

• Promote good nutrition and regular exercise.

• Encourage stress management and healthy habits

what can be given to decrease the rate of preterm birth and labour?

prophylactic progesterone- daily vaginal suppositories or creams and weekly intramuscular injections

why give progesterone?

• preserve excitement/contractions of uterus to get it to relax

what is used to supress uterine activity?

• tocolytics

  • used to supress labour

what are some common types of tocolytics?

• nifedipine

• indomethacon

• magnesium sulphate

• nitroglycerin

contraindications of tocolytics - maternal

• severe pre-eclampsia or severe gestational diabetes

• significant vaginal bleeding 

• intrauterine infection (chorioamnionitis- infection of amnotic sac)

• cardiac disease

• medical or obsterical condition that contraindicates continuation of pregnancy 

contradindications of tocolytics- fetal

• gestational age of 37 weeks or more

• fetal demise

  • stillbirth

• lethal fetal anomaly

  • birth defect that results in baby no surviving after birth 

• acute or chronic fetal compromise

  • not getting enough oxygen in womb

what is given to promote fetal lung maturity before preterm birth?

• antenatal glucocorticoids

how do antenatal glucocorticoids help the baby?

• speed up fetal lung development by stimulating surfactant production

why is surfactant production important

• keeps the baby air sac open after birth, helping the baby breathe

why is magnesium sulphate used in inevitable preterm birth?

• to protect baby brain and reduce risk of neuro problems such as cerebal palsy

what should be explained to pt. and family when giving tocolytic therapy?

• purpose is to stop/slow contractions and the possible adverse effects

what postion should the pt be in when giving tocolytic therapy

• lateral position to enhance improve blood flow to placenta and reduce pressure on cervix

what should be assessed during this time

• vital signs 

  • lung sounds

  • resp effort

• fetal HR

  • pattern 

• labour status 

  • frequency and strength of contractions

• assess labour pt. and fetus for signs of adverse reactions 

• measure intake and output 

• provide pyschosocial support to pt and family

what to do with early symptoms for preterm labour

• bedrest

• empty bladder

• drink 2-3 glasses of water or jucie

  • enhance blood supply

• lie on side for 1 hour

• palpate contractions 

what to do if your symptoms still continue?

• call HCP and go to hospital

what to do if symptoms go away

• resume light activity but not what you were doing before symptoms arised

what to do if symptoms return?

• call HCP or go to hospital

for what symptoms should u call HCP or go to the hospital immediiatley?

• uterine contractions every 10 mins for 1+ hour

• vaginal bleeding

• leakage of amnotic fluid

what is PROM?

• spontaneous rupture of amniotic sac and leakage of amniotic fluid that starts before labour at any gestational age

what is pPROM

• rupture of membranes before the complication of 37 weeks of gestations

what are the risk factors for PROM

• history of prior preterm birth, esp if associated w/ preterm PROM 

• history of cervical surgery or cerclage 

• urinary or gential tract infection 

• short ( less than 25mm) cervical length (noted on transvaginal ultrasound)

• preterm laboyr or symptomatic contractions in current pregnancy 

• uterine overdistension

  • overstretched 

• second and third trimester bleeding

• pulmonary bleeding

• connective tissue disorder

• low socioeconomic status

• low body mass index

• nutritional deficiency

• smoking 

what two nutritional deficiencies

• copper 

• ascorbic acid 

what does care depend on

• based on risk of maternal, fetal and newborn complications

what to do for term pregnancy?

• induction of labour

how is PROM managed at 34-36 weeks?

• conservative management (watch and wait) if low risk for intrauterine infection

how is PROM managed before 32 weeks

•  Expectant/conservative management to allow fetal lung maturity and reduce preterm complications, unless contraindicated.

when is expectant/conservative management NOT recommended 

• if is there

  • intrauterine infection

  • significant vaginal bleeding

  • placental abruption

  • advanced labour

  • atypical or abnormal fetal assessment

how is fetal health assessed in preterm PROM

• using NST, BPP to check fetal wellbeing and amniotic fluid volume

what meds are given for preterm PROM?

• Antenatal corticosteroids 

  • 24–34+6 weeks) → accelerate fetal lung maturity

• Broad-spectrum antibiotics

  • 7-day course to prevent infection

  • (e.g., ampicillin/amoxicillin + erythromycin)

• Magnesium sulphate

  • (<34 weeks) → fetal neuroprotection

how should fetal movement be monitored?

• Patient should count fetal movements daily.

• Expect 6 movements in 2 hours.

• If fewer, further testing (NST, BPP, or both) is needed.

what infection sign should be reported to HCP immediatly?

• foul smelling vaginal discharge 

• maternal and fetal tachycardia 

what hygiene instructions should be given to pt.

• Keep the genital area clean

• Nothing should be introduced into the vagina

maternal complications of PROM?

• chorioamnitoitis-bacterial infection of the amniotic cavity

• placental abruption

• retained placenta and hemorrhage sepsis and death 

How is chorioamnionitis diagnosed

• maternal fever

• maternal and fetal tachycardia

• uterine tenderness

• foul odour of amnitiotic fluid 

what factors increases the risk of chorioamniotiis?

• prolonged membrane rupture

• multiple vaginal exams

• use of internal FHR and contraction monitoring modes

• young maternal age

• low socioeconomic status

  • no to minimal prenatal care

• nulliparity

• pre-exisiting infections of the lower genital tract

what is the management for chorioamniotiis?

• IV broad spectrum antibotics (ampicillin or penicillin and gentamicin)

What additional antibiotics may be given after cesarean section?

• Clindamycin or metronidazole (Flagyl)

what are the fetal complications of PROM?

• intrauterine infection 

• cord prolapse and umbilical cord compression associated with oligohydramnios

  • cord comes out faster than babys head

  • pressure on umblical cord, does not get enough blood supply, end up with hypoxemia 

what is post term pregnancy?

• pregnancy that goes beyond the end of week 42 of gestation or more than 294 days from the first day of the LMP

what are the risk factors for post term preganancy?

• first pregnancy

• prior post term

• male fetus

• obesity 

• genetic predispostion 

what are maternal risks for post-term pregnancy?

• labour dystocia

• severe perineal injuries 

• chorioamnionitis

• endomyometritis

  • inflammation of outer layer, muscular uterus d/t infection 

• postpartum hemorrhage

• ceasarean birth

• anxiety

• risk of morbidity during intrapartum period

fetal risks of post term pregnancy?

• macrosomia 

  • risk w/ mothers w/ GDM

• small for gestational age 

• shoulder dystocia

• birth tramua 

• aphyxia

  • deprieved of oxygen

• oligohydramnios

  • cord compression

    • abnormal HR

• aging placenta

  • can apply support until 42 weeks, then worse supply

• stillbirth

• meconium-stained amniotic fluid, meconium aspiration

  • baby stool in amnotic fluid, baby breathes of causing resp problems

• low apgar scores

• convlusion in newborn

  • seziures

when does antepartum fetal assessment begin for post-term preganancy?

• beginning at 41 weeks of gestation

what tests are included in antepartum fetal assessment

• Daily fetal movement counts

• Nonstress tests (NSTs)

• Amniotic fluid volume (AFV) assessments

• Contraction stress tests

• Biophysical profiles (BPPs)

• Doppler flow measurements

what should patients do for daily fetal monitoring at home?

• Count fetal movements daily

• Watch for signs of labour

• Call healthcare provider if:

  • Membranes rupture

  • Fetal movements decrease or stop

Why are appointments for fetal assessment and cervical checks important?

• To monitor fetal well-being and detect complications early.

when is birth reccomeneded for post-term preganancies

• By 42 weeks and no later than 42 + 6 weeks

• This reduces risk of perinatal morbidity and mortality

what is dystocia

• abnormally slow progress of labour

• difficult, does not follow normal delivery

how slow is the progress of labour for dystocia?

• greater than 4 hours of less than 0.5 cm per hour of cervical dilation in active labour OR

• greater than 1 hour of active pushing with no descent

how does powers affect dystocia?

• ineffective uterine contractions or bearing-down efforts(pushing effects of mother)

• most common cause 

how does passageway affect dystocia?

• CHANGE IN SHAPE OF PELVIS

• changes in pelvic structure, abnormalities of labouring patient’s bony pelvis or soft tissue abnormalities of reproductive tract

how does passanger affect dystocia?

• fetal causes, abnormal presentation or position, anomalies (abnormalities or defects in baby), 

  • transverse/oblique/breech → not good

  • cephallic→ good

how does position affect dystocia?

• postion of patient during labour or birth 

  • supine, standing, squatting?

how does psychological reponse affect dystocia?

• past experiences, prep, culture, heritage, support system

supportive care for dystocia?

• supportive care by nurse 

  • health care team approach 

  • electronic fetal monitoring 

  • ultrasonography to identify potential labour complications related to fetus

    • abnormal fetal position

    •  pelvis of pregnant patient

  • risk assessment is continous process to identify dysfunctional labour

  • prevention

interventions for dystocia

• external cephalic vision

  • move pt. from breech to cephaliac

• cervical ripening 

  • put foley in vagina with balloon, if cervix dilates, it will fall out 

• induction or augmentation of labour 

• operative procedures

• c-section

what are complications of labour dystocia?

• fetal distress

• risk of maternal and neonatal infections

• postpartum hemorrhage

• uterine rupture

• increased risk of pelvic floor, gential, perineal tramua

• increased risk of uterine or pelvic organ prolapse

• increased risk obsterical fistula (vesico-vaginal or rectovaginal fistula) and incontinence

  • abnormal opening, feces or urine comes through vagina 

• sacroiliac joint dislocation

  • connects pelvis to spine

prolapsed umbilical cord?

• descending part of baby puts pressure on cord → lack of blood supply and o2

• cord sneaks out before baby

how do u know of a cord prolapse when doing a vag exam?

• feel the skull pulsating

umbilical cord prolapse patho

What is the main goal in managing umbilical cord prolapse

• To relieve pressure on the umbilical cord and maintain fetal oxygenation until delivery (usually by C-section).

What immediate position should the client assume to relieve cord compression?

• Knee-to-chest position or Trendelenburg position to use gravity to lift the presenting part off the cord.

What manual intervention can be done by the healthcare provider?

• Manual decompression

  • using a gloved hand to gently elevate the presenting fetal part off the cord until proper cervical dilation.

What should be done if the umbilical cord is protruding from the vagina?

• Keep the cord warm and moist (using sterile saline-soaked gauze) to prevent vasospasm and further compromise of blood flow.

  • warm wet towel?

What medication may be used to reduce uterine contractions?

• A tocolytic (e.g., terbutaline) can be administered to slow contractions and reduce pressure on the cord.

What are warning signs that may indicate a cord prolapse

• A sudden gush of fluid followed by a feeling of vaginal pressure or fullness.

What should the patient do if they suspect a cord prolapse before help arrives?

• Immediately assume a knee-chest position and call for emergency assistance—do not attempt to push the cord back in.

Why is maintaining pressure off the cord critical?

• Compression of the cord decreases fetal blood flow and oxygen supply, risking fetal hypoxia and death.

what do u do if if cervix is not fully dilated or risk of
fetal compromise is high?

• c-section

what is shoulder dystocia?

• head is born but anterior shoulder cant pass under pubic arch

what causes shoulder dystocia?

• fetopelvic disproportion caused by excessive fetal size 

  • more than 4000g

  • macrosomia

• pelvic abnormailities

  • mother has small pelvis

• prolonged second stgae of labour

• history of shoulder dystocia with previous birth

what are the two first-line interventions for shoulder dystocia?

• McRoberts maneuver

• suprapubic pressure

• gaskin manoeuvre

what is McRoberts maneuver

• legs are hyperflexed on abdomen 

  • legs to chest 

• suprapubic pressure-applied over anterior shoulder 

  • fundal pressure should be avoided

    • apply pressure to pelvis not the uterus

what is the gaskin manoeuvre?

• place patient in all positions with hands and knees postion

what are the complications of shoulder dystocia

• brachial plexus (erb palsy), phrenic nerve injuries 

• fracture of humerus or clavicle

• asphyxia 

  • baby not getting enough oxygen 

what is amniotic fluid embolism (AFE)

• amniotic fluid leaks into the circulation(bloodstream) of labouring patient during labour, during birth, within 30 mins after birth,

what 3 things happen when AFE happens?

• resp distress

• circulatory collapse

• hemorrhage

what happens in resp distress?

• restlessness

• dyspnea

• cyanosis

• pulmonary edema

• resp arrest

what happens in circulatory collapse?

• hypotension

• tachycardia

• shock

• cardiac arrest

what happens with hemmorhage

• Coagulation failure

  • DIC

• Uterine atony

  • uterus fails to contract after delivery

• mortality rate is 61% or higher

what are the risk factors?

• advanced age

• non-White race

• placenta previa

• pre-eclampsia,

• forceps-assisted or Caesarean birth

what to do for AFE?

• oxygenate

• maintain cardiac output and replace fluid loss

• adminster IV fliods

• adminster blood; packed cells, fresh frozen plasma

• insert cathether and measure hourly urine 

• correct cogulation failute

• monitor fetal and maternal status 

• prepare for emergency birth once patiennt condition has stabilized 

• provide emotional support

how should the patient be oxygenated

• non-breather face mask 10L.min or resuscitation bag delivering 100% oxygen

• prepare for intubation and mechanical ventilation

• intiate or assist CPR

• tilt pregnant patient 30 degrees to side to displace uterus

how should the patient be position

• on their side