Labor and birth complications

Preterm labor

same as regular labor but occurs between 20-36 6/7 weeks

• regular contractions with cervical effacement or dilation

• not always painful with preterm labor

Preterm birth

occurs between 20-36 6/7 weeks

• 37 weeks is considered full term

Strategies to decrease preterm birth

1. Improved fertility practices — cannot implant more than 2 fertilized embryos

2. Limiting elective scheduled late preterm births — only consider for medication indication 

• delivering a baby at less than 39 wks of gestation due to uncontrolled diabetes, preeclampsia, cholestasis, or lack of placental oxygen

3. increased strategies to prevent RECURRENT preterm birth

• progesterone: qualify if you’ve had 3 or more miscarriages in a row; if you have 1 successful labor they may still give; receive injections throughout pregnancy

• cerclage: sew cervix shut; supports a weak or incompetent cervix; cervix closed until pregnancy reaches viable gestational age

Categories of preterm

• very preterm: <32 weeks

• moderately preterm: 32-34 weeks

• late preterm: 34-36 6/7 weeks

  • 35-36 weekers have a hard time breastfeeding and keeping blood sugar and temperature up

Preterm Birth vs Low Birth Weight

• preterm birth/ prematurity: LENGTH of gestation regardless of birth weight

  • less time in uterus = immature body systems ESP lungs (less surfactant)

• Low birth weight <= 2500 gm at birth REGARDLESS of gestational age

  • many potential causes, including preterm

  • intrauterine growth restriction (result in feeding difficulties and trouble keeping temp up)

Spontaneous vs Indicated preterm birth

• Spontaneous: underlying infectious process (chorio); may not have fever or feel sick but something in the uterus got infected so the body starts to contract; PPROM; 75% of preterm births

• Indicated: preeclampsia, maternal infection, IUGR, medically induced/ planned preterm delivery for maternal and fetal safety; 25% of preterm births

Causes of Spontaneous preterm labor

• multiple pathological processes (pelvis pathway is incompatible with birth)

• infection

• congenital uterine abnormalities

• placental causes (body detects something is wrong and goes into labor to clear the contents of the uterus)

• maternal and fetal stress

• uterine distention (multiples [2 or more babies], severe polyhydramnios [a lot of amniotic fluid])

How to predict Spontaneous PTL and birth

• risk factors, often spontaneous (hx of preterm birth or infection)

• cervical length= >30 mm in 2nd and 3rd trimester are unlikely to give birth prematurely

Fetal Fibronectin (fFN) test

• glycoprotein glue in plasma and produced during fetal life

  • glue that helps baby sac attach to the uterine lining

  • baby emits this protein, do a vaginal swab

  • used to predict who will NOT go into PTL

  • between 22-35 weeks, it shouldn’t be present in significant amounts

  • neg test <1% chance of birth within the next 2 weeks

  • helps avoid unnecessary interventions (hospitalization, tocolytics, corticosteroids)

  • HOWEVER positive test not very predictive of preterm birth (a lot of things can give a false positive)

What medication is used to suppress uterine activity?

Tocolytic meds

• toco = related to contractions

• Ex: Nifedipine

• only to be used for a couple days, not for long term use

• used to delay delivery for steroids

What is the primary purpose of administering Nifedipine?

to delay delivery until Betamethasone can be administered

What is Betamethasone used for?

to promote fetal lung maturity

• helps babies produce surfactant, speed up maturation of the lungs

• reduces incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, death

• Mom gets 2 doses over 24 hours

• IM injection, can burn

Management of the inevitable preterm birth

• give magnesium sulfate 

  • helps baby’s lungs and slows contractions; prevents brain bleeds, seizures; give 2 grams/hr, get within 24 hours of deliver, continuous infusion

• gestational age of viability is 22-26 now, but high probability of lifelong disability

PROM

premature rupture of membranes

• spontaneous rupture of amniotic sac and fluid leakage PRIOR to labor onset AT TERM

• baby is FULL TERM

• water breaks prior to them being in labor, NO CONTRACTIONS

PPROM

preterm, premature rupture of membranes

• membranes rupture before 37 weeks gestation

• need antibiotics asap (typically ampicillin and gentamycin 24-48 hours)

• often preceded by infection

Chorioamnionitis

infectious process of 1 of the 2 layers of amniotic sac OR entire contents of uterus is infected

• outer, closer to mom

• can’t really test which part of amniotic sac is infected

• major cause of complications at any GA

• common reason for C section, but also failure to progress in labor and fetal distress

• dx: maternal fever, sustained maternal & fetal tachycardia, uterine tenderness (late finding of chorio, won’t feel if she had an epidural), foul order of amniotic fluid

• tx: ampicillin and gentamycin

Management of care for PPROM

• watch weight

• may not intervene, just watch on the monitor continuously

  • mom may go into labor or may get an infection

• watch for signs of infection, fetal assessment, temp q4, non-stress test each shift

• antenatal glucocorticoids for PPROM from 24-36 5/7 weeks

  • babies at 37 weeks do not qualify for betamethasone

• broad spectrum antibiotics

• magnesium sulfate for fetal neuroprotection

What is the biggest contributor to chorioamnionitis in labor?

manually breaking the water

• only break water if clinically appropriate, not before

Postdates

42+ weeks of gestation

• <0.5% all births in US, we don’t let them go that far

Maternal and fetal risks to postdate pregnancy

• increased maternal morbidity 

• dysfunctional labor, birth trauma (significant tears), macrosomia (large baby)

  • shoulder dystocia or operative birth risks increase (vacuum or forceps)

• labor and birth interventions increase (higher C section rates)

• significant perinatal morbidity/mortality increase after 42 weeks

Post maturity syndrome

• past expected growth pattern

• dry skin, almost cracked appearance

• long nails and toenails

• long hair

• meconium in amniotic fluid

Fetal assessment for postterm labor

• NST (non-stress test)

• AFI (amniotic fluid index): measures amniotic fluid in womb

• contraction stress test (CST): start mom on Pitocin, want three contractions within 10 mins

  • make sure baby is oxygenated, if not they baby needs to come out

• Pt assesses fetal activity daily: see how long it takes to get 10 kicks

  • more than 2 hours is BAD

• instead of AFI they’ll do a DVP, less false positives

  • normal = 2-8 cm deep vertical pocket on ultrasound

dystocia

lack of labor progress for any reason

dysfunctional labor

long, difficult, or abnormal labor

• 2-3 contractions and then 7-8 mins of nothing

Arrest of labor

no progress; initially normal progress into active phase, then contractions become weak, ineffective, or stop

precipitous labor

• dysfunctional or abnormal

• labor lasting <3 hours from onset of contractions to time of birth

causes of dystocia (fetal causes)

• anomalies

• cephalopelvic disproportion (CPD): head too big to come out of pelvis

• malposition (baby is transverse or oblique lie)

• malpresentation (breech)

causes of dystocia (position of mom)

• appropriate maternal positions + effect on strength of contractions, fetal position, mother’s pelvis

  • mom may feel better if she’s walking, upright position is good = stronger contractions to help baby descend

causes of dystocia (psychological responses)

• hormones and neurotransmitters released in response to stress can cause dystocia

• sources of stress and anxiety (don’t want to poop, don’t want mother-in-law there)

• talk to them, find what’s holding them back

induction of labor definition

the chemical and/or mechanical initiation of uterine contractions BEFORE the spontaneous onset, for the purpose of bringing about birth

elective induction of labor and risks

induction without medical indication (at maternal or provider convenience)

• risks: increased rates of cesarean birth, increased length of labor, medicalized birth experience (vacuum/forceps), increased cost r/t longer hospital stays, medical care etc.

• should not be initiated until 39 weeks

• consider: is the pt fully informed, what is the institution C section rates, can the institution handle the extra workload (short staffed, census)

Bishop’s score

a rating system used to evaluate the “inducibility or cervical ripeness”

• cervix is firm or soft; posterior, mid or anterior; dilated? effaced?

• consider why they are asking for an induction

• >= 8: favorable, high likelihood of induction success resulting in a vaginal delivery 

• 6-7: intermediate, cervix is moderately favorable, may consider cervical ripening

• <= 5: unfavorable, induction would likely fail, use prostaglandins, foley balloon before oxytocin

Cervical ripening methods (chemical, mechanical, physical)

• Chemical: Misoprostol/cytotech (given orally, used to be vaginally but it causes too many contractions & Cervidil (tiny tampon with same meds, nice because you can take it out at any time)

• Mechanical/physical: balloons (cook’s catheter, inflate in vagina and then cervix)

oxytocin and Pitocin induction of labor

• nipple stimulation released oxytocin, stronger than artificial (Pitocin)

• stimulates uterine contractions, aids in milk let down

• synthetic oxytocin used to induce labor progressing slowly d/t inadequate uterine contractions

  • get more than 5 contractions in 10 mins

  • can cause uterine tachysystole (uterine rupture and/or fetal demise) bc every contraction is like baby holding their breath

  • designated as a high-risk drug

Amniotomy

artificial rupture of membranes

• good if it’s your 4th or 5th baby

• and 4-5 cm dilated

Forceps assisted birth

• used to be routine for vaginal deliveries

• trauma to vagina, bladder, scarring of baby face or facial nerves

• if baby is crooked coming down, it can be used to turn baby, can do BEFORE she starts pushing

Primary risk related to use of forceps is ___ ____ r/t ____ ____

nerve compression related to bell’s palsy

Vacuum assisted birth

• get three shots and if baby doesn’t come out then C section is needed

• time when the vacuum started 

• prepare for shoulder dystocia

VBAC

vaginal birth after cesarean

TOLAC

trial of labor after cesarean

• not offered in many places or not truly supported

reasons for elective cesarean birth

• no medical indication, never gave birth

• doesn’t happen, babies may not feel need to cry = lower APGAR

reasons for scheduled cesarean birth

• usually repeat C section

• when placenta covers the cervix = placenta previa

• if baby is breech or transverse

reasons for unplanned cesarean birth 

• urgent: not making progress, mom gets a fever, baby has decelerations

• emergent: placenta separates, placenta previa bursts, cord prolapse

types of C section cuts

• low transverse: most common

• classical cut: difficult, emergency for preterm baby because baby is high in the uterus, contraindicated with vaginal birth

• low vertical incision: when access is limited (deeply engaged head, abnormal position)

Anesthesia for C section

• npo 6 hours prior

• patients with scoliosis can get an epidural but the doctor may need guided imagery

morbidly adherent placenta

an abnormal placental attachment

• accreta: attached deeply

• percreta: attached so deeply it’s on the uterus and the bladder

• placenta can attach to a uterine scar and if you cut through it, it can cause a hemorrhage

risks of obesity in pregnancy

increased risk for complications: pregnancy associated hypertensive disorders, gestational diabetes, cesarean birth, venous thromboembolism

intrapartum challenges of obesity in pregnancy

• standard furniture isn’t large enough, fetal monitoring can be difficult, routine procedures require more time and effort, moving quickly in ER is difficult

postoperative challenges in obese pregnancies

• increased risk for blood clot formation

• keeping incision clean, dry, and intact to prevent wound infection and promote healing

  • pannus: a large roll of abdominal fat that causes the area to remain moist

external cephalic version (ECV)

attempt to turn fetus from breech or shoulder presentation to vertex

• 36-37 weeks: 65% success, risk for cesarean reduced

• stop if resistance is met, takes 5-10 mins

• usually very uncomfortable

• premedicate with fentanyl or give meds through epidural

meconium-stained amniotic fluid

• fairly common, used to be considered an emergency

• if they poop and they leave mom, they can aspirate it

• indicates fetus has passed stool prior to birth 

• dark green/black/tar-like

• possible causes: stress, breech presentation, normal physiological function of maturity, hypoxia-induced peristalsis, umbilical cord compression 

shoulder dystocia

• the head is born but the anterior shoulder CANNOT pass under the pubic arch

• head is bobbing in and out of pelvis

• high risk if baby is big

• interventions

  • McRoberts maneuver (hyper flexing mom’s thighs toward her abdomen)

  • supra-pubic pressure, HOB down

  • Gaskin maneuver (flip onto all fours) & lunge (hard if epidural is in already)

Newborn birth injuries from shoulder dystocia (main concern)

• asphyxia (esp if longer than 30 secs)

• brachial plexus damage

• fracture

maternal risk from shoulder dystocia

• excess blood loss d/t uterine atony or rupture

• lacerations or extension of episiotomy 

• endometritis 

• ask her to push harder, make sure there’s a stool

prolapsed umbilical cord

cord lies below presenting part of fetus

• contributing factors: AROM (don’t break if baby is -3), long cord, malpresentation (breech), transverse lie, unengaged presenting part

nursing care prolapsed umbilical cord

• prompt recognition, pressure off cord, position change to keep pressure off cord, emergent C/S

uterine rupture

symptomatic disruption and separation of uterine layers or previous scar

• most frequent cases: scar separation from previous classic C/S; uterine trauma (accidents and surgery)

uterine dehiscence

• incomplete rupture; separation of prior scar

amniotic fluid embolus (AFE)

• aka anaphylactoid syndrome of pregnancy, rare but devastating

• sudden, acute onset

• hypotension, hypoxia, hemorrhage

• caused by coagulopathy 

• amniotic fluid with particles of fetal debris (hair, vernix, skin cells, meconium)

  • enters maternal circulation

  • obstructs pulmonary vessels

  • respiratory distress

  • circulatory collapse

  • often fatal

Biophysical profile

• prenatal test used to assess fetal wellbeing, especially in high-risk pregnancies

• evaluates fetal oxygenation and neurological function through ultrasound and FHR monitoring

• 8-10 is normal

• 6 means you should retake it in 24 hours

• 4 or less means fetal hypoxia (immediate delivery)

A pregnant woman arrives to the L&D unit and informs the nurse her baby is breech. She wishes to undergo a ECV to manually reposition the baby. What next intervention would support this procedure and increase the likelihood of success?

a. Tocolysis

b. Nitrous oxide (to relax mom)

c. spinal or epidural analgesia

d. amnioinfusion

a. Tocolysis