Nursing Care during Labor and Birth at Risk

maternal risks for preterm labor

low SES, age <16 or >40, lack of social support, IPV, non-caucasian race, less than high school education, previous preterm birth/family hx of preterm birth, increased parity, obesity, medical and obstretical complications, uterine fibrioids, perceived stress, infections, substance abuse/use, poor nutrition, > or < BMI, work conditions, short spacing

etiology of PTL

• hx of preterm birth

• bacterial vaginosis

• intraamniotic infection

• intrauterine inflammation

• PROM

• multiple gestation: due date closer to 36 weeks

• bleeding: 2nd and 3rd trimester

• Uterine/cervical abnormalities

s/sx PTL

uterine activity, discomfort: indigestion, cramping + back pain (rhythmic), vaginal discharge

Biochemical markers for PTL

FFN, endocervical length

FFN

only used if patient thinks they’re in preterm labor

• Neg: 97% chance pt is not delivering at that moment

• Pos: active preterm labor

Endocervical length

only used if pt is predisposed to preterm labor

• looks for lack of effacement; 14-16 weeks; only if pt has preterm labor hx

• if <25mm effacement measurement; potential preterm labor

Home care for PTL

ONLY IF FETAL FIBRONECTIN IS NEG;

• provide education: back pain, indigestion is sign for preterm labor

• assessments

• interventions: progesterone supplements in women with hx

Hospital care for PTL

ONLY IF FETAL FIBRONECTIN IS POSITIVE; medications: tocolytics, steroids, preterm birth

neonatal risks

LBW, RDS, infection, birth injury, asphyxia, hyperbilirubemia, other complications of prematurity

PROM

premature rupture of membranes

precipitous labor

< 3 hours from first contraction to birth; very fast labor

dystocia

slow labor

obesity

BMI >30 kg/m2

morbidly obsese

>40kg/m2

complications from obesity

DVT, C/birth, emergency c/birth, wound infection

induction of labor methods

cervical ripening, amniotomy, oxytocin

cervical ripening

• chemical agents: prostaglandins

• mechanical methods: foley balloon

foley balloon used if ROM

yes

foley balloon used if NO ROM

no

amniotomy

artificial rupture of membranes: amnihook

exogenous oxytocin used if bishop score

is 9 or greater

Induction of labor indications

post date pregnancy, IUGR, PROM with infection, maternal health risks

Contraindications IOL

known CPD, herpes outbreak, malpresentation, placenta previa, previous vertical uterine incision

operative vaginal deliver interventions

instruments are used to help delivery fetal head during 2nd stage

operative vaginal delivery indications

maternal exhaustion, fetal compromise

operative vaginal delivery

FORCEPS, VACUUM

forceps

used to deliver fetal head

• Outlet: introitus 

• Low: +2 station 

• Midpelvis: 0 to +2 station 

  • Risks are fetal skull or neck injury, bruising, maternal lacerations, hematoma 

    • Epidural anesthesia: NICU TEAM SHOULD BE PRESENT 

Vacuum

• Similar indications to forceps 

• Suction apple to fetal scalp, rather than pulling on entire head 

• Thought to be less traumatic to fetus but can cause scalp injury and hematoma 

  • Nursing role 

    • Explain procedure 

    • Inform parents of risks: possible bruising 

    • Monitor FH

    • If needed generate vacuum pressure in “green zone”; document 

    • Observe neonate for jaundice, anemia 

  • NICU TEAM SHOULD BE PRESENT  

c section indications

prior c section, fetal distress

c section complications and risks

bleeding, infection, injuries, anesthesia (intubation)

preoperative c section

• Desire NPO x 6 hrs 

• Bicitra: neutralizes stomach acid 

• Foley: bladder needs to be empty

• Clip lower abdomen 

• IV 

• Strip on fets 

postoperative c section

• In PACU VS Q15 mins; Temp Q1 hr; O2- 1 hr pp 

• Assess uterus and bleeding 

• Help splint incision 

labor after c section risks

uterine rupture

labor after c section contraindications

women with previous vertical uterine incisions

attempting VBAC

• MD must be available (OB and anesthesia)

• Must be able to perform stat C section

Post term pregnancy

pregnancy/birth after 42 weeks gestation

post term pregnancy tests

NST and Biophysical profile

NST

2x/week

Biophysical profile is bad

Do contraction stress test to see if baby tolerates labor

Maternal and fetal risks post term pregnancy

• Excessive fetal size (macrosomia) 

• Postmaturity syndrome d/t placental insufficiency

  • Weight loss, decreased AFV, meconium staining/aspiration, fetal distress, resp distress, hypoglycemia

Risk of meconium aspiration syndrome (MAS)

• neonate inhales mec mixed with AF upon first breath or while in utero

• pneumonia

Management of post term labor

• Close fetal monitoring after 40 weeks: NST/AFI

• Labor induction: prevent stillbirth, avoid meconium aspiration 

• Amnioinfusion: can relieve pressure on cord 

  • Can relieve decels 

obstretical emergencies

shoulder dystocia, prolapsed umbilical cord, uterine rupture, amniotic fluid embolism

shoulder dystocia

head is delivered but shoulders are too large

shoulder interventions

• McRoberts Maneuver: sharply flex the maternal thighs on to abdomen

• Suprapubic Pressure: release the anterior shoulder

• Gaskin Manuever: hands and knees position; requires mobility

shoulder sign

Turtle’s sign (head delivered but sucked back in)

shoulder timing

should not be longer than 3-5 minutes (baby can be acidotic)

prolapsed umbilical cord

cord falls next to below presenting part

prolapsed umbilical cord sign

EFM- sudden prolonged variable decels, mother may say she feels something pulsating in vagina

prolapsed umbilical cord causes

neg station, breech baby

Uterine rupture

complete uterine wall separation with direct exposure of the internal uterine cavity to the peritoneal cavity

Uterine rupture

• Uterus splits or tears

  • Usually related to 

    • Prior uterine surgery (C- section, myomectomy) 

      • Myomectomy-surgery removes benign tumors, fibroid, etc.

      • Thin uterus- grand multip 

      • Anatomical defect 

uterine rupture s/sx

hypovolemic shock, bleeding into abdomen

uterine rupture tx

immediate cesarean delivery for mother and infant

sometimes hysterectomy

Amniotic fluid embolism

bubble of AF enters maternal vascular system

• enters cardiac and pulmonary space

• results in immediate CHF and possible DIC

amniotic fluid outcome

maternal mortality= 50%

amniotic fluid risk factors

rapid labor, uterine surgical extensions, AMA, eclampsia

amniotic fluid signs

changes in maternal LOC, resp distress, hypotension, cardiac arrest, hemorrhage

amniotic fluid embolism nursing interventions

oxygenated→ get help

bacterial vaginosis characterized

thin, greyish, odor (fish like) discharge

bacterial vaginosis testing

swab→microscope→ treat with antibiotics

PROM

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

PPROM (preterm PROM)

PROM before 37 weeks gestation

Prolonged ROM

ROM more than 24 hrs before birth