Chapter 17 - Labor and Birth Complications

NUR 390 - Maternal, Newborn, and Women's Health; Mississippi College

when complications arise, perinatal _____ and _____ increase

morbidity; mortality

some complications are _____, particularly when mother is identified as high risk. others are _____ or _____.

anticipated; unexpected or unforeseen

it is crucial for nurses to _____ normal birth processes, _____ and _____deviations from normal labor and birth, and _____ nursing measures if complications arise 

understand; prevent and detect; implement 

nurse and obstetric team must use knowledge and skills in a _____ effort to provide care in event of complications

concerted 

what is the gestational age between for preterm labor?

20 0/7 and 36 6/7 weeks

what is preterm labor generally diagnosed clinically as?

• regular contractions along with a change in cervical effacement, dilation, both, or presentation with regular uterine contractions and cervical dilation of at least 2 cm

what occurs with a spontaneous preterm birth?

occurs with or without ROM

what are some causes of spontaneous preterm birth?

• ***history of genital tract colonization, infection, or instrumentation

• African-American race

• bleeding of uncertain origin in pregnancy

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

• uterine anomaly

• use of assisted reproductive technology

• multifetal gestation

• cigarette smoking, substance abuse 

• pre-pregnancy underweight (BMI<19.6) and pre-pregnancy obesity (BMI>30)

• periodontal disease 

• limited education and low socioeconomic status 

• late entry into prenantal care

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

what is BMI stand for?

body mass index

indicated preterm birth is _____ to resolve maternal or fetal risk related to pregnancy

necessary

what is a risk factor for spontaneous preterm labor and birth?

living in a disadvantaged area and lack of access to prenatal care

how could we predict a spontaneous preterm labor and birth?

cervical length

what do we test for fetal fibronectin test (fFN)?

cervical and vaginal secretions

what does a fetal fibronectin test (fFN) indicate?

placental inflammation

what are the common causes of indicated preterm birth?

• preexisting or gestational diabetes 

• chronic hypertension 

• preeclampsia 

• obstetrical disorder or risk factors in the current or a previous pregnancy 

• previous cesarean birth via a vertical or T-shaped uterine incision 

• cholestasis 

• placental disorders (abruption or previa) 

• medical disorders 

• seizures 

• thromboembolism

• connective tissue disorders 

• asthma and chronic bronchitis 

• maternal HIV or active herpes infection 

• obesity 

• smoking 

• AMA

• fetal disorders

• fetal compromise 

• chronic (poor fetal growth) 

• acute (abnormal results on a NST or BPP) 

• excessive (polyhydramnios) or inadequate (oligohydramnios) amniotic fluid 

• fetal hydrops, ascites, blood group alloimmunization 

• birth defects 

• fetal complications of multifetal gestation (e.g. growth deficiency, twin-to-twin transfusion syndrome)

what does BPP mean?

biophysical profile

what does HIV mean?

human immunodeficiency virus

what does NST mean? 

non stress test 

what are some signs and symptoms of preterm labor?

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

• increase in amount of vaginal discharge

• pelvic or lower abdominal pressure

• constant low, dull backache

• mild abdominal cramps, with or without diarrhea

• regular or frequent contractions or uterine tightening, often painless

• ruptured membranes

*NOTE: a woman in preterm labor may have only one or all of these signs

what do we do if symptoms of preterm labor occur?

• stop what you are doing

• lie down on your side

• drink two to three glasses of water or juice

• lie down on your side

• wait 1 hour

• if symptoms get worse, call your HCP

• if symptoms go away, tell your HCP what happened at your next prenatal visit

• if symptoms come back, call your HCP

when do we assess for preterm labor?

assess for risk factors early on and continuously 

what are some interventions for preterm labor?

prevention, early recognition and diagnosis, and lifestyle modifications

what are some preventions for preterm labor?

• more cost-effective than treating premature conditions

• progesterone (daily or weekly IM)

what are some lifestyle modifications for preterm labor?

• activity restriction (modified bed rest)

• restriction of sexual activity (pelvic rest)

• home care (have items within reach, move couches or chairs next to windows, etc.)

what is tocolytics?

delay birth long enough and to administer corticosteroids for lung maturity or treatment of tachysystole

what should we monitor for terbutaline (brethine) off-labeled use SubQ?

• chest pain

• cardiac arrythmias

• myocardial infarction

• pulmonary edema

what should we monitor for magnesium sulfate (off-labeled use)?

s/s of magnesium toxicity 

what is indomethacin/nifedipine used for?

cardiac

what are antenatal glucocorticoids used to promote?

fetal surfactant production, fetal lung maturity, and reduction of fetal respiratory distress.

how and when are antenatal glucocorticoids given?

IM between 24-36 weeks gestation 

are antenatal glucocorticoids painful?

yes

how much, where, and when are betamethasone given?

12 mg IM for 2 doses 24 hrs apart

how much, where, and when are dexamethasone given?

6 mg IM for 4 doses 12 hrs apart 

how would we manage an inevitable preterm birth?

• mag sulfate IV infusion for neuroprotection (off-label prevention of cerebral palsy) 24-32 wks gestation ideally if they will likely deliver in 24 hours

how would we care for a patient who just went through fetal and/or early neonatal loss?

• be prepared to handle delicate and sensitive situations

• palliative care vs neonatal resuscitation (situational)

• mother may not want to stay on unit with crying babies

what is premature rupture of membrane (PROM)?

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

when does preterm premature rupture of membranes (pPROM) usually occur?

membrane rupture before 37 weeks of gestation

what is a major risk factor for pPROM?

infection

which race is pPROM twice as prevalent in?

African-Americans 

what are some things that cause pathologic weakening of the amniotic membranes?

chorioamnionitis (inflammation/infection), stress from uterine contractions (increased intrauterine pressure), other factors: smoking, previous history, short cervix 

will labor likely be induced for PROM?

yes

pPROM is managed conservatively if risk of intrauterine infection is _____ (low/high)?

low

for pPROM, of 34-36 weeks gestation, pursuit of labor and birth is _____ (likely/unlikely)?

likely 

is pPROM patients usually hospitalized?

yes

what are we monitoring for in pPROM?

• daily BPP/NST, DMFC

• glucocorticoid for lung maturity

• 7-day course of antibiotics (i.e. ampicillin/amoxicillin and erythromycin) to prevent infection

• mag sulfate (CP prevention)

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