Labor and Birth Complication chapter 32

Regular uterine contractions along with cervical changes (effacement and/or dilation) occurring at a preterm gestation

preterm labor

Condition of inadequate fetal growth not necessarily correlated with the initiation of labor

Intrauterine growth restriction

Spontaneous rupture of the amniotic sac and leakage of amniotic fluid before the onset of labor at any gestational age

PROM

Refers to a lack of progress in labor for any reason

dystocia

Abnormal labor caused by excessive fetal size in relation to the size of the maternal pelvis. The fetus is too large to be born vaginally

__________ or fetopelvic disproportion (FPD)

cephalopelvic disproportion (CPD)

Labor pattern that lasts less than 3 hours from the onset of contractions to the time of birth, sometimes resulting from hypertonic uterine contractions that are tetanic in intensity

precipitous labor

Pregnancy that extends to 42 0/7 weeks of gestation or more

postterm

Uncommon obstetric emergency in which the head of the fetus is born but the anterior shoulder cannot pass under the pubic arch

shoulder dystocia

two main causes of shoulder dystocia

FPD, maternal pelvic abnormalities

Obstetric emergency in which the umbilical cord lies below the presenting part of the fetus; it may be occult (hidden) or more commonly frank (visible)

prolapsed umbilical cord

Symptomatic disruption and separation of the layers of the uterus or previous scar; it is a rare but life-threatening obstetric injury occurring during labor and birth

uterus rupture

Uterus rupture major risk factor

scarred uterus

Rupture of the uterus -Symptomatic disruption and separation of the layers of the uterus or previous scar; it is a rare but life-threatening obstetric injury occurring during labor and birth. The major risk factor for its occurrence is a scarred uterus, and it usually occurs during _____________________________

trial of labor for attempted vaginal birth after cesarean (VBAC)

_____________

An antenatal glucocorticoid administered ____________to accelerate fetal lung maturation when there is risk for preterm birth; its use results in an increase in the production and release of surfactant

Betamethasone, IM

Beta2-adrenergic agonist; it relaxes uterine smooth muscles, treat uterine tachysystole, or to suppress contractions prior to cesarean birth

Terbutaline (Brethine)

Terbutaline (Brethine) route of admin

subcut

A calcium channel blocker administered orally; it relaxes smooth muscles, including those of the contracting uterus; ______________ is a concern

Nifedipine (procardia), maternal hypotension

Classification of medications given to arrest labor after uterine contractions and cervical change have occurred

tocolytic

A central nervous system (CNS) depressant used during preterm labor for its ability to relax smooth muscles, including those of the uterus; it is administered _____

Magnesium Sulfate, IV

prostaglandin synthesis inhibitor that relaxes uterine smooth muscles; it is administered orally.

Indomethacin (Indocin)

Terbutaline (Brethine)

Tocolytic medication administered subcutaneously to suppress __________ and inhibit uterine activity

uterine tachysystole

Oxytocin (Pitocin)

Pituitary hormone used to stimulate uterine contractions in the augmentation or induction of labor and also used to control ___________

pp bleeding

__________

Cervical ripening agent, used in the form of a tablet that is most commonly inserted ________ in the posterior fornix

Misoprostol (Cytotec), intravaginally

Cervical ripening agent in the form of a vaginal insert that is placed in the posterior fornix of the vagina

Dinoprostone (Cervidil)

Cervical ripening agent in the form of a gel that is inserted in the cervical canal just below the internal os

Dinoprostone (Prepidil)

Classification of medications that can be used to ripen the cervix, stimulate uterine contractions, or both

prostaglandin

Natural cervical dilator made from desiccated seaweed

Laminaria tent

Synthetic cervical dilator containing magnesium sulfate.

lamicel

PTL

premature labor

PTL: early recognition & diagnosis

• admin _____ during labor

• admin antenatal glucocorticoids (i.e, betamethasone) to at risk for premature birth to prevent/reduce morbidity & __________ & intraventricular hemorrhage

• Admin Magnesium Sulfate to women giving birth before ____ gestation to reduce incidence of Cerebral Palsy (CP)

antibiotics, RDS, 32 wks

PTL: s/sx

• change in type of vaginal discharge (watery, mucus, bloody)

• increase in amount of vaginal discharge

• _________________

• constant, low , dull _______

• mild ABD cramps, with or w/o diarrhea

• regular or frequent contractions or uterine tightening, often _______

• ruptured membranes

pelvic or lower abd pressure, backache, painless

PTL: self-management

• stop what you are doing

• _________

• drink ___ glasses of water or juice

• Wait 1-h

• if symptoms get worse, call OB. If they go away, tell OB at next visit

lie on side, 2-3

PTL: lifestyle mods

• bed rest

• hydration

• ________

• pelvic rest

limited work

Tocolytic therapy (PTL)

• position on her ____ to enhance placental perfusion & reduce pressure on cervix

• monitor maternal VS (lung sounds, respiratory effort, FHR and pattern, labor status)

• assess for signs of adverse reactions

• assess maternal fluid balance by measuring daily weight & ________

• limit fluid intake to _________, esp. if terbutaline or mag sulf given

• comfort, relaxation techs

side, i&o, 2500-3000 mL/day

Magnesium Sulfate: considerations

• assess women & fetus to obtain baseline

• IV usually, can be given IM

• optimal range: ________

• ensure calcium gluconate available

• DO NOT give to women with ____, hypocalcemia, renal failure

• total IV intake should be limited to _______

5-8 mg/dL, MG, 125 ml/h

Magnesium Sulfate: adverse effects

• hot flushes, sweating, ____________, n/v, dry mouth drowsiness, blurred vision, diplopia, headache, ileus, generalized muscle weakness, lethargy, dizziness

• __________

• Dyspnea

• Transient ________

burning IV site, hypocalcemia, hypotension

Magnesium Sulfate: adverse effects- Intolerable

• respiratory rate _____

• pulmonary edema

• _________

• chest pain

• severe hypotension

• altered LOC

• extreme muscle weakness

• __________UOP

• serum Mg >9mg/dL

<12, absent DTRs, <25mL/h

Terbutaline (Brethine): adverse effects {Most mild & limited duration}

• _______, chest discomfort, palpitations, arrythmias

• tremors, dizziness, nervousness

• headache

• nasal congestion

• n/v

• _________

• _______

• hypotension

tachycardia, hypokalemia, hyperglycemia

Terbutaline (Brethine): adverse effects: INTOLERABLE

• tachycardia ______

• BP <90/60 mm Hg

• chest pain

• cardiac arrhythmias

• ____

• pulmonary edema

>130 bpm, MI

Terbutaline (Brethine): considerations

• should not be used in known/suspected heart disease, ______, __________, hyperthyroidism, glaucoma, seizure disorder

• assess maternal ____ & _______ levels

• ensure _____ available to reverse effects r/t cardiovascular function

PGDM, GDM, preeclampsia w/ severe features, glucose, potassium, propanolol

Indomethacin (Indocin): Adverse effects- maternal

• GI bleeding

• prolonged bleeding time

• _________ in aspirin-sensitive clients

asthma

Indomethacin (Indocin): Adverse effects- fetal

• ______________

• oligohydramnios

• neonatal pulmonary _______

constriction of ductus arteriosus, hypertension

Indomethacin (Indocin): considerations

• use only if < 32wks gest.

• admin for 48-h or less

• DO NOT use in women with ___________, active peptic ulcer disease, poorly controlled HTN, _____, or coagulation disorders

• determine AFV and function of fetal ductus arteriosus before therapy

• admin ______

• monitor for signs of ____

renal/hepatic disease, asthma, with food, PPH

t or f?

nifedipine masks maternal fever

f, indomethacin

Nifedipine (Procardia): considerations

• DO NOT GIVE to women with _________, ________, or cardiac disease

• __________

• should not be given simultaneously with or after terbutaline

• do not use sublingual route

intrauterine infection, htn, avoid with magnesium sulfate

membranes rupture before37-0/7 weeks of gestation ​

PPROM

PPROM often preceded by infection (i.e, ________)

chorioamnionitis

PPROM at less than ___weeks is managed expectantly or conservatively​

32

Interprofessional Care Management​: PROM and PPROM

• Antenatal glucocorticoids for all women with preterm PROM between __ 0/7 and _ 0/7 weeks of gestation ​

• 7-day course of broad-spectrum antibiotics ​

• Administering magnesium sulfate for fetal neuroprotection​

24-34

Preterm PROM conservative management

• daily fetal assessment (___& biophysical profile (BPP))

• s/sx infection

• antenatal glucocorticoids

• 7-day anbx

• mag sulf

NST

• Bacterial infection of the amniotic cavity ​

• Major cause of complications for mothers and newborns at anygestational age

Chorioamnionitis

Chorioamnionitis s/sx

• ___________

• maternal & fetal tachycardia

• __________

• purulent amniotic fluid

maternal fever, uterine tenderness

Chorioamnionitis- Neonatal risks

• ______

• bacteremia

• meningitis

• death

pneumonia

Chorioamnionitis tx

• IV broad-spectrum antibiotics (______ or penicillin)

• ___________

ampicillin, birth of fetus

Post term- Maternal risks

• severe ____ injuries

• chorioamnionitis

• __________

• PPH

• ________

perineal, endomyometritis, cesarean birth

t or f? post term preg. increases feelings of resentment towards fetus

t

Post term- Fetal risks

• macrosomia → operative birth, shoulder dystocia

• decreased amniotic fluid → ________

• meconium-stained fluid → ________________

cord compression, meconium aspiration

Post-term: care management

• NST, ___, BPP, or

• ___________ at least once a week

  woman is encouraged to assess fetal activity daily, assess for signs of labor, and keep appointments with her obstetric health care provider

CST, modified BPP

low-lying placenta

placenta previa

Obesity- preg

higher risk for ______, _______, fetal congenital abnormalities

post-term preg., longer labor, emergency c-section

VTE pp, wound disruption and infection, ____

spontaneous abortion, stillbirth, PPH

Turning fetus from breech or shoulder presentation to vertex presentation

Gentle, constant pressure on abdomen

External cephalic version (ECV)

What must be done before ECV (external cephalic version)?

US

External cephalic version (ECV)

• US before

• ____ to confirm fetal-well-being or FHR & pattern are monitored for a period of time

• tocolytic agent such as _______ to relax uterus

NST, Terbutaline

T or F?

ECV does not require informed consent

F

ECV (external cephalic version): contraindications

• uterine anomalies

• _________

• __________

• ______________

• Evidence of uteroplacental insufficiency

• ___________

• Previous cesarean or uterine surgery

• Obvious CPD

Third trimester bleeding, multiple gestation, oligohydramnios, Nuchal cord

Rating system used to evaluate inducibility

8 or more good

Bishop score

Amniotomy: artificial rupture of membranes

BEFORE: _________ of the fetus should be engaged and well applied to the cervix to prevent ________

Presenting part, cord prolapse

Amniotomy: woman’s temp checked at least every

2-h

More than five contractions in 10-min averaged over a 30-min window

Uterine tachysystole

Oxytocin (Pitocin): adverse

• uterine tachysystole, ___________, uterine rupture

• Fetal: compromise, hypoxia, neonatal ______

Placental abruption, acidemia

Oxytocin

Contractions should NOT occur more frequently than every _____

2-min

Augmentation of Labor

• ____________

• Ambulation

• Position changes

• Relaxation measures

• Nourishment and hydration

• Hydrotherapy

Emptying the bladder

Operative vaginal birth

Assisted with

Forceps, vacuum

Cesarean: PreOp

NPO for at least ____ before the surgery

8-h

Cesarean

Clear liquids may be permitted up until ____ before surgery

Blood tests are usually done 1 or 2 days before

Admin _____ and ________ to reduce the risk of aspiration pneumonia

Avoid hypothermia

2-h, antacids, histamine h2 receptor agonists

_________: PostOp

• prevent n/v

• Offer regular diet 2-h after. Gum chewing if delayed

• Use multimodal analgesics for pain control

• SCD boots or TED hose

• Early ambulation

• Remove foley

Cesarean

Cesarean PostOp

• BP & pulse assessed every ____ for two hours

• Temp assessed every 4-h for first 8-h, then every 8-h

• Skin-skin contact, alone time w baby

• Patent airway

• Respirations, lochia, UOP, IV intake

• ___________

15min, oxytocin

Cesarean postop

AVOID: gas-forming foods, ________, carbonated bevs, _________

Ice chips, drinking with a straw

Meconium-stained amniotic fluid

1. Normal physiologic function

2. ____________

3. _____________-induced vagal stimulation

Hypoxia, cord compression

Major risk associated with Meconium-stained Amniotic Fluid

Meconium aspiration syndrome (MAS)

Meconium-stained amniotic fluid: interventions

• ___________

• MAYBE: Suction only the newborns _________, using bulb or large-bore suction catheter (IF BABY HAS: strong respiratory effects, good muscle tone, heart rate greater than ______)

• Suction trachea IF BABY: decreased respirations, decreased muscle tone, HR <100BPM

Assess respirations, HR, muscle tone, mouth & nose, 100bpm

Shoulder dystocia: s/sx

• slowing in the progress of the second stage of labor

• Formation of a ____ ______ that increases in size

• ___________

• No external rotation occurs

Caput succedaneum, fetal head retraction (turtle sign)

Maternal complications of Shoulder Dystocia

• fourth degree lacerations

• ____

PPH

Shoulder Dystocia: Care Management

Women’s legs flexed against ABD

SUPRAPUBIC PRESSURE APPLIED

McRoberts maneuver

Shoulder Dystocia: Care Management

_________ should NOT be applied

Fundal pressure

Shoulder Dystocia: Care Management

Hands-and-knees position

Gaskin maneuver

Shoulder Dystocia: Care Management

Interventions: stay calm, ________, help positioning pt., document, encourage

Call assistance

Prolapsed Umbilical Cord: intervention

Hold presenting part off cord

Prolapsed Umbilical cord: aiding positions

Lateral recumbent, Trendelenburg, knee-chest

Prolapsed Umbilical Cord: protruding from the vagina

• wrap loosely in

Sterile towel with warm sterile NS

Prolapsed Umbilical Cord:

____________ → immediate vaginal birth

If not → cesarean birth

Cervix dilated

Rupture of the Uterus: findings

• __________ as evidenced by ______, late or variable decelerations

• Absent baseline variability

• Tachycardia Or Bradycardia

• ____________

• Sudden SHARP ABD pain

• Ripping or tearing sensation

• Bright red vaginal bleeding

• Hypovolemic shock symptoms

• Fetal parts may be palpable through abd

Abnormal FHR tracing, abrupt decrease in FHR, LOSS of fetal station

Rupture of Uterus: best treatment is PREVENTION

• past c-section → avoid vaginal births

• Watch for _________

• Signs of bleeding

Uterine tachysystole

Rupture of Uterus:

small rupture → _____ and birth of infant, repair of laceration, __________

Laparotomy, blood

Rupture of Uterus:

Large rupture → __________ needed if difficult to repair or woman Hemodynamically unstable

Hysterectomy

sudden, acute onset of hypotension, hypoxia, hemorrhage caused by coagulopathy

Amniotic fluid embolus

Amniotic Fluid Embolus: s/sx

• respiratory distress

• Restlessness

• Dyspnea

• Cyanosis

• Pulmonary edema

• Respiratory ______

• Circulatory collapse : ___________, tachycardia, shock. Cardiac arrest

• Hemorrhage: ____________

• Uterine atony

Arrest, hypotension, coagulation failure

Amniotic Fluid Embolus: Interventions

• ______________

• Prep for intubation and mechanical ventilation

• Initiate or assist with _________. Tilt women _______ to her side

• IV fluids, blood products, IUC w hourly measurements

• Monitor

Oxygen nonrebreather or resus bag, CPR, 30 degrees