Nursing Management of Labor and Birth at Risk

dystocia

slow, abnormal progression of labor that includes lack of dilation and descent of the fetal head; usually diagnosed during the active phase of the 1st stage of labor; “failure to progress”

what are the risk factors for dystocia?

epidural analgesia/excessive analgesia, multiple gestation, hydramnios, maternal exhaustion, ineffective maternal pushing effort, occiput posterior position (back labor), longer first stage of labor, nulliparity, short maternal stature, fetal birth weight over 8.8lb, abnormal fetal presentation or position, fetal anomalies, maternal age over 35 tears, high caffeine intake, overweight, gestational age over 41 weeks, chorioamnionitis, ineffective uterine contractions, high fetal station at complete cervical dilation

what is hypertonic uterine dysfunction?

uterus never fully relaxes, contractions ineffective, prolonged latent phase, placental perfusion impaired; this is a problem with power in dystocia

what is the nursing management of hypotonic uterine dysfunction?

promote rest and relaxation; administer oxytocin, assist with amniotomy, ambulate, continuous EFM, assess for maternal/fetal infection, educate

what is first stage arrest?

associated with power issues in dystocia; > 6cm dilated, ROM, and one of the following: > 4hrs adequate UC or > 6 hrs UCs

what is second stage arrest?

associated with power issues in dystocia; 10cm to birth; nulliparous, lack of progress > 3hrs (w/epidural) or > 2 hrs w/o epidural; multiparous, lack of progress > 2hrs (w/epidural) or > 1hr w/o epidural

what is precipitous labor?

very fast labor - birth < 3 hours from start of contractions, hypertonic UCs < 2mins apart lasting > 60 secs; expect a category II tracing; risk to fetus from asphyxia due to hypertonia, risk of physical injury to both birthing person and fetus, risk of postpartum hemorrhage

what is the nursing management of precipitous labor?

closely monitor contractions and FHR, may administer tocolytics, stay with patient, inform HCP, anticipate delivery

what are the problems with the passageway during dystocia?

pelvic contraction of diameter inlet, mid-pelvis, or outlet; obstructions in maternal birth canal: placental previa, full bladder, fibroids, cervical edema, genital warts

what are the problems with the passenger during dystocia?

occiput posterior position - labor usually longer, associated with severe back pain, maternal exhaustion, extensive caput; breech/transverse presentation, face/brow presentation, multifetal pregnancy, macrosomia and cephalopelvic disproportion (CPD), structural abnormalities

what is external cephalic version (ECV)?

refers to a procedure in which the fetus is rotated from the breech to the cephalic presentation by manipulation through the mother’s abdomen; risks include placental abruption, ROM, bradycardia

what is shoulder dystocia?

vaginal delivery of the anterior shoulder is obstructed by the symphysis pubis and/or an impaction of the posterior shoulder on the maternal sacral promontory (rarely); complications are maternal injury, risk of fetal injury, risk for postpartum hemorrhage

what is the turtle sign?

in shoulder dystocia when the head draws back against the perineum after delivery and body doesn’t deliver

what is the nursing management of shoulder dystocia?

recognize and intervene immediately, stop pushing and lay the bed flat, assist w/MacRoberts Maneuver/suprapubic pressure, assist w/Gaskin maneuver, provider will attempt delivery of the anterior shoulder, woods corkscrew maneuver, episiotomy if dr needs more room for hands, Zavanelli maneuver

what is the MacRoberts maneuver?

push head in and try to free the shoulder

how can psychological distress cause dystocia?

sympathetic nervous system activation; release of stress hormones that reduce uterine contractility; stress hormones lead to reduced uterine perfusion; intense fear can reduce pain tolerance

what are some nursing management of psychological distress during labor?

trauma informed care, environment control, encourage partner participation, keep pt informed/effective communication, encourage relaxation and comfort techniques, educate

what is the nursing assessment for dystocia?

hx of risk factors (GDM), maternal frame of mind, vital signs, uterine contractions, fetal heart rate, fetal position

T/F psychological stress in childbearing people can contribute to dystocia.

True

what are the risk factors for spontaneous preterm labor?

hx of preterm labor is the biggest; genital tract infection, multi-fetal gestation, second-trimester bleeding, PROM, low pre-pregnancy weight

what are the risk factors for indicated preterm labor?

pre-eclampsia, fetal distress, intrauterine growth restriction, abruptio placentae, placenta previa, diabetes, renal disease

what are the causes of preterm labor?

infection (and inflammatory response), bleeding at the site of placental implantation, uterine over distension, decrease in progesterone

what is the nursing assessment for preterm labor?

gestational age between 20-37 weeks, uterine activity 4 UCs/20 mins or 8 UCs/hr, progressive cervical change, CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length via transvaginal ultrasound

what is the fetal fibronectin test?

glycoprotein found in early and late pregnancy; used as diagnostic tool, vaginal swab; protein positive 22-35 weeks = high risk of PTL, protein negative = 99.2% will not have PTL, test is good for two weeks; the negative test is more accurate

what is the therapeutic management of preterm labor?

betamethasone for lung maturity, antibiotic prophylaxis for suspected/presumed infection, tocolytic drugs; goal is to prolong pregnancy 2-7 days to give steroids for lung maturity, client education, psychological support, prepare client for what to expect w/preterm newborn

what are tocolytics?

slow down/stop contractions; magnesium sulfate, beta-adrenergic agonist meds, calcium channel blockers, NSAIDS

what is postterm labor?

post-term pregnancy: 42 weeks or > gestation; 41-41 6/7 weeks = late term pregnancy; unknown etiology

what are some maternal risks for postterm labor?

cesarean birth, dystocia, birth trauma, postpartum hemorrhage, infection

what are some fetal risks for postterm labor?

uteroplacental insufficiency, macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, dysmaturity = FGR, cephalopelvis disproportion, meconium aspiration

what is the nursing assessment for a post-term pregnancy?

estimated DOB, daily fetal movements counts, nonstress tests twice weekly, amniotic fluid measurement, weekly cervical exams; management - fetal surveillance, decision for labor induction, support, education and intrapartal care

what is umbilical cord prolapse?

umbilical cord delivers before presenting part; partial or total occlusion of cord with rapid fetal deterioration; may be occult (hidden); absolute obstetric emergency

what is the nursing assessment for umbilical cord prolapse?

prevention, risk factors - malpresentation, hydramnios, AROM above -2 station etc risk factors, continuous assessment of client and fetus

what is the nursing management for umbilical cord prolapse?

prompt recognition, measures to relieve compression; gravity helps avoid cord compression

what is placenta previa?

placenta partially or completely covering vaginal os, high risk for hemorrhage, cesarean birth required

what is vasa previa?

fetal vessels traverse the membranes close to the cervix unprotected by the placenta or umbilical cord; vessels are at risk of compression

what is placental abruption?

obstetric emergency involving premature separation of placenta from uterine wall; management dependent on gestational age, extent of hemorrhage, and maternal-fetal oxygenation perfusion; maintenance of maternal CV status; prompt delivery of fetus; cesarean birth if fetus is still alive, vaginal birth if fetal demise

what is uterine rupture?

tear in all layers of uterus; obstetric emergency, onset marked by sudden fetal bradycardia, possible loss of fetal station

what is the nursing assessment for a pt with uterine rupture?

onset of sudden fetal distress, other signs, risk of hemorrhage

what is the nursing management for a pt with uterine rupture?

preparation for urgent cesarean birth, continuous maternal and fetal monitoring

what is amniotic fluid embolism (AFE)?

amniotic fluid containing fetal particles enters maternal blood stream; rare and often fatal, fetal and maternal hypoxic neurologic damage

what is the nursing management of a pt with AME?

recognize symptoms — sudden onset of hypotension, cardiac collapse, and respiratory distress; resuscitation, 100% oxygen; IV fluids to maintain cardiac output/BP; hemorrhage control; steroids for inflammatory process; seizure precautions; transfer to ICU

what is uterine inversion?

fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out; rare complication of vaginal or cesarean delivery; occurs after delivery

what is a 1st degree uterine inversion?

incomplete; fundus is within the endometrial cavity

what is a 2nd degree uterine inversion?

complete; the fundus protrudes through the cervical os

what is a 3rd degree uterine inversion?

prolapsed; fundus protrudes to or beyond the introitus

what is a 4th degree uterine inversion?

total; both the uterus and vagina are inverted

what is the nursing management of uterine inversion?

discontinue uterotonic drugs, call for immediate assistance, establish inadequate IV access and aggressive fluid/blood product resuscitation, do not remove the placenta, immediately attempt to manually replace the inverted uterus, give uterine relaxants, prepare for surgical repair, oxygen, blood transfusions

which of the following assessment findings would lead the nurse to suspet an amniotic fluid embolism?

a. respiratory distress

b. hypertension

c. acute abdominal pain

d. sudden fetal distress

a. respiratory distress

what is labor induction?

deliberate stimulation of UCs before the onset of spontaneous labor to facilitate a vaginal delivery

what is labor augmentation?

enhancing ineffective contractions after labor has begun; progress labor after labor has started

what are the indications of labor induction?

prolonged gestation, PPROM, gestational hypertension, cardiac disease, renal disease, intrauterine fetal demise, isoimmunization, diabetes, intrahepatic cholestasis of pregnancy

what are the indications of labor augmentation?

choriomanionitis/Triple I, dystocia

what is the therapeutic management to induce labor?

cervical ripening, herbal agents, castor oil, hot baths, enema, sexual intercourse with breast stimulation, mechanical methods and surgical methods, pharmacological agents, oxytocin

what is the nursing management during labor induction?

relative indications, gestational age determination, fetal status, maternal status, Bishop score

what is the Bishop’s score?

score of 8 or greater is favorable for induction, a score of 6 or less is unfavorable, if induction is indication, cervical ripening agents may be utilized; score uses dilation cm, effacement %, station, consistency of cervix, cervical position

describe cervical ripening

the process of physical softening, thinning and dilation or the cervix in preparation for labor and birth; mechanical cervical ripening: hygroscopic dilators, transcervical balloon catheter; pharmacological methods of cervical ripening: prostaglandins

what does “sweeping or stripping of membranes” mean?

vaginal exam + physical separation of the amnion from the wall of the cervix and lower uterine segment; evidence is limited

what is an amniotomy?

the artificial rupture of membranes; used to induce or augment labor; an amnihook is used to break the bag of waters during an sterile vaginal exam; make sure station is at 0; it helps release prostaglandins; risks include infection and prolapsed cord

what is the nursing assessment for an amniotomy?

ensure the head is firmly engaged, continuous monitoring of FHR, assess amniotic fluid for signs of infection, blood or clear, meconium etc.

what is endogenous oxytocin?

synthesized by the hypothalamus; excreted by posterior pituitary; released in response to vaginal/cervical stretching

what is exogenous/synthetic oxytocin?

identical to endogenous oxytocin; onset of action: 3-5 mins; half-life: 10 mins; does not cross the placenta

what are some risks to oxytocin administration?

water intoxication, hypotension, uterine hypertonicity

what is the nursing management of oxytocin administration?

titrate oxytocin according to hospital policy, continuous EFM, assess fluid balance, q2h v/s

T/F oxytocin is an important agent used to ripen the cervix for labor induction

false

describe amnioinfusion.

instillation of fluid into uterus via IUPC; usually normal saline and membranes must be ruptured;

what are some indications for amnioinfusion?

severe variable decelerations d/t cord compression; oligohydramnios d/t placental insufficiency; postmaturity or rupture of membranes; preterm labor with premature rupture of membranes; thick meconium fluid

what is the nursing management while administering amnioinfusion?

teaching, maternal and fetal assessment, preparation for possible cesarean birth

what are the indications for a forceps and vacuum delivery?

maternal exhaustion, inability to push effectively; medical indications such as maternal cardiac disease; second stage arrest; nonreassuring FHR patterns in the second stage of labor; limited sensation or inability to push effectively; presumed fetal jeopardy or fetal distress; infection

describe vacuum assisted delivery.

soft cup placed on the occiput with negative pressure; fetal injury; maternal injury; can only be done by providers with hospital privileges; the fetal head must be engaged and cervix completely dilated

what is the nursing management with patients that undergo vacuum-assisted deliveries?

EFM, mark application time, and amount of time for each pull; mark pop-offs; assess for neonate injury, assess for maternal injury, educate

describe forceps assisted delivery.

metal instruments look like large tongs, lock so as not to crush fetal skull, outlet forceps and low forceps, fetal injury, maternal injury; can only be done by providers with hospital privileges; the fetal head must be engaged and cervix completely dilated

what is the nursing management with patients that undergo forceps-assisted deliveries?

EFM, mark application time and amount of time for each pull, assess maternal tissues for damage and hemorrhage, assess fetal face and skull for soft tissue damage, educate

describe cesarean birth.

classic or low transverse incision; major surgical procedure with accompanying risks

what are the three c/s classifications?

emergency c/s indicates an immediate need to delivery the fetus

urgent c/s indicates a need for rapid delivery of the fetus

nonurgent c/s indications a need for cesarean birth related to complications

describe a scheduled c-section.

scheduled c/s occur before the onset of labor; reasons for scheduled c/s include previous cesarean birth and maternal or fetal health conditions that place the pregnant person or fetus at risk during labor or vaginal birth; malpresentation diagnosed before labor

common causes of unscheduled c-sections

have an urgent or emergent cause; arrest of labor, abnormal FHR tracing (cord prolapse, abruption)

what are the risks of c/s?

PPH, infection, fetal or maternal injury, anesthesia complications

how do you prevent primary c/s?

implement the ACOG standardized definition and management of labor dystocia; use standardized FHR interpretation and management; use cervical ripening agents for IOLs; allow longer durations of the latent phase; require oxytocin be given for at least 12-18hrs after ROM; use labor support to promote physiological birth

what is the nursing management for a cesarean birth?

pre-operative readiness: skin prep, NPO; preoperative blood work, education, informed consents, EFM/NST, assess PPH risk, u/s for fetal and placental lie, OR circulator/scrub duties, cord blood gas, quantify blood loss (QBL), enhanced recovery after cesarean (ERAC)

what is TOLAC?

the planned attempt to deliver vaginally after a previous c/s; patients that desire a vaginal delivery can achieve a VBAC

describe VBAC.

vaginal birth after cesarean; associated with decreased risk of complications in future pregnancies, decreased maternal morbidity, patients that want more children are encouraged to attempt a VBAC, avoids risks of surgery and abnormal placental implantation

what is perinatal loss?

pregnancy loss or neonatal death up to 1 month of age; includes miscarriage, fetal demise; may have devastating effects/affect whole family; higher impact on communities more greatly at risk for SDOH; high risk for postpartum depression/post-loss depression

what is the nursing assessment for pt going through perinatal loss?

signs of impending loss: vaginal bleeding, loss of fluid, decreased/absent fetal movement, pain; absent fetal heart tones, emotional response

what is the nursing management for pt going through perinatal loss?

routine assessments and management of complications, emotional support and connecting to resources

what is intrauterine fetal demise?

numerous cases; fetal death at 20 weeks gestation or greater

what is the nursing assessment for pt going through intrauterine fetal demise?

inability to obtain fetal heart sounds; ultrasound to confirm absence of fetal activity; labor induction

what is the nursing management for pt going through intrauterine fetal demise?

assistance with grieving process, referrals