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OB/ Maternity Ch. 19

Labor and Birth at Risk

Preterm Labor Cervical changes and uterine contractions occurring between 20 and 37 weeks. Preterm birth any birth occurring before the completion of 37 weeks of pregnancy.
Risk factors associated with preterm birth Nonwhite race, Age less than 15 or more than 35 years, low socioeconomic status, unmarried, less than HS education, previous preterm birth labor or birth, grand multiparity, progesterone defieciency, multiple gestation, Cervical insufficiency, medical dx
Biochemical Markers Fetal fibronectin and salivary estriol. Fetal fibronectin are glycoproteins found in plasma and produced during fetal life. Their appearance between 24-34 weeks predicts labor, done through vaginal exam
Endocervical Length Women whose cervical length is more than 30 mm before 34 weeks of gestation are less likely to have a preterm birth than women whose cervical length is less than 30 mm.
Causes of preterm birth and labor Infection is thought to be a major contributing factor. Smoking, substance abuse, poor nutrition, work, fatigue, sexual activity, short interpregnancy interval.
Maternal characteristics of preterm labor and birth Young or older women,previous preterm birth, short stature, short cervix, uterine anomalies, prematurely dilated cervix, low pregnancy birth weight, victim of domestic violence, stress ,PROM, lack of prenatal care, anemia, multiple gestation, stress.
Prevention One of the most important nursing interventions is aimed at preventing preterm birth is the education of pregnant women about the early symptoms of preterm labor so that if symptoms occur the women can be referred to her care provider for intensive care.
Education about Preterm Birth Educate women that waiting too long to see a HCP could result in inevitable preterm birth without the benefit of administration of antenatal glucocorticoids to accelerate lung maturity placing the neonate at increase risk of respiratory distress.
Signs and symptoms of Preterm Labor Uterine contractions more frequent than every 10 minutes persisting for one hour or more,UC painful or painless, lower abd cramping, dull intermittent low back pain, painful menstrual like cramps,suprapubic pain, pelvic pressure, urinary frequency.
Signs and symptoms of Preterm Labor continued Change in the character and amount of usual discharge- thicker (mucoid), thinner (watery), bloody, brown or colorless, increased amount or odor, rupture of amniotic membranes.
Diagnosis of preterm labor Gestational age of 20-37 weeks, uterine activity and/or contractions, Cervical change of 80% effacement or 2cm or greater dilation.
Interventions Bedrest, activities resulting in preterm labor such as sexual activity, riding long distances, carrying heavy loads,standing more than 50% of the time, heavy housework, climbing stairs, physical work. Homecare may also be provided.
Tocolytics Administration of pharmaceutical agents that supress uterine activity. A gain of 48 hours to several days is the best outcome that can be expected if dilation is less than 6cm. Allow adm. of antenatal glucocorticoids to accelerate fetal lung maturity.
Tocolytics commonly used terbutaline( Brethine), magnesium sulfate, indomethacin (Indocin), and nifedipine ( Procardia).
Contraindications for tocolysis Maternal: Severe Preeclampsia or eclampsia, active vaginal bleeding, intrauterine infection, cardiac disease, dilation greater than 6cm, medical or obstetric contraindicating continuation of pregnancy.
Fetal contraindication for tocolysis Estimated gestational age greater than 34 weeks, fetal death, lethal fetal anomaly, acute fetal distress, chronic intrauterine growth restriction.
Antenatal Glucocorticoids Given as an IM injection to mother to accelerate fetal lung maturity. Women should be between 24-34 weeks of gestation should be given antenatal glucocorticoids when preterm birth is a threat inless there is a medical indication for immediate delivery.
Management of Inevitable Preterm Birth Labor that has progressed to a cervical dilation of 4 cm is likely to lead to inevitable preterm birth.
Premature rupture of membranes The rupture of amniotic sac and leakage of amniotic fluid beginning at least one hour before the onset of labor at any gestational age.
Symptoms of PROM Complaints of either a sudden gush of fluid or a leak of fluid from the vagina. Infection and umbilical cord compression are serious side effects of PPROM. Complications include congenital pneumonia, sepsis, and meningitis.
Nursing Care of PPROM Examinations should be avoided unless there is suspicion that the birth is imminent. Women should be taught how to count fetal movements daily. Signs of infection: fever, foul smelling vaginal discharge, maternal and fetal tachycardia.
Fetal Movement Monitoring 10 movements in a 12 hour period or 4 movements after every meal in a 2 hour period.
Dystocia Long, difficult, or abnormal labor. Caused by Alterations in pelvic structure, Fetal causes including abnormal presentation or position, anomalies, excessive size, # of fetuses, Maternal position during labor and birth, dysfunctional labor.
Dysfunctional Labor Abnormal uterine contractions that prevent the normal progress of cervical dilation. effacement, or descent.
Hypertonic Uterine Dysfunction Contractions usually occur in the latent stage and are usually uncoordinated . The force of the contraction may be in the midsection of the uterus rather than the fundas, therefore the uterus is unable to apply downward pressure to push against the cervix
Hypertonic Uterine Dysfunction After 4 to 6 hours of rest women are likely to awaken in active labor with normal uterine contraction pattern. Therapeutic rest can be achieved by warm bath, analgesics.
Hypotonic Uterine Dysfunction The woman usually makes progress into active labor then the contractions become weak and inefficient or stop all together. Management consists of performing ultrasound to determine fetal positioning and FHR , maternal wellbeing, and amniotic fluid.
Malpresentation Most common malpresentation is the breech position. There is a risk of prolapse of the umbilical cord if the membranes rupture in early labor. The presence of meconium in amniotic fluid can result from pressure on the fetal abdominal wall.
Abnormal labor patterns Can result from ineffective uterine contractions, pelvic contractures, CPD, abnormal fetal presentation or position, early use of analgesics, nerve block anesthesia, and anxiety/stress.
Precipitous Labor Labor that lasts less than 3 hours from the onset of contractions to the time of birth. Maternal complications can include uterine rupture, lacerations of the birth canal, postpartum hemorrhage. Fetal complications hypoxia and intracranial hemorrhage.
Version The turning of the fetus artificially from one presentation to another by a physician.
Induction of Labor The chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about the birth. Reasons include hypertension, DM,chorioamnionitis, and other maternal medical conditions.
Cervical Ripening Methods IV Oxytoxin and amniotomy most common methods. Preparations of prostaglandin E1and2 can be used before induction to soften and thin the cervix. Balloon Cathetars, Dilators, and tents can also be used by absorbing fluid and the expansion causes dilation.
Amniotomy Artificial ROM. Can be used to induce labor when the condition of the cervix is favorable or to augment labor if the process begins to slow. Labor usually begins within 12 hours of rupture and is decreased by up to 2 hours especially with oxytoxin.
Amniotomy Procedure Assess for signs of infection and condition of cervix and station of presenting part. Assess FHR to obtain baseline and after. Assess color, consistency. and odor of fluid. Temp every two hours. Assure women procedure is painless for her and fetus
Oxytoxin Stimulates uterine contractions. Special caution needed for multifetal presentation, breech presentation, abnormal FHR, polyhydramnious, grand multiparity, and maternal cardiac disease.
Tachystole More than 5 contractions in a 10 minute period may reduce the blood flow through the placenta and result in FHR changes and fetal asphyxia leading to neonatal hypoxia.
Augmentation of Labor Stimulation of uterine contractions after labor has started spontaneously but progress has not been satisfactory.
Forceps assisted births Instrument with two curved blades is used to assist in birth of fetal head. Maternal indications for use include maternal disease that inhibits pushing efforts. Fetal indications include certain abnormal presentation, arrest of rotation, abnormal FHR.
Vacuum Assisted Birth Attachment of vacuum cup to the fetal head , using negative pressure to assist in the birth of the head. Risk to infant include cephalhematoma, scalp lacerations, subdural hematoma.
Cesarean Birth Indications most commonly associated with C Section include consistent abnormal FHR, CPD, malpresentations such as breech, umbilical cord prolapse, dysfunctional labor pattern, placental abnormalties, multiple gestation.
Complications and Risk of C Section Maternal complications include aspiration, pulmonary embolism, wound infection, wound dehiscence, thrombophlebitis, hemorrhage, UTI, injuries to the bladder,ureters, or bowels, anesthesia complications.
Forced Cesarean Birth If a women refuses a C section that is recommended because of fetal jeopardy. HCP must make every effort to find out why she is refusing and provide info to persuade a change of mind. HCP must decide if it is ethical to get a court order for surgery.
Anesthesia Spinal, epidural and general anesthetics are used for cesarean birth.
Prenatal Preparation Blood and urine tests are usually done a day or two before planned cesarean birth or on admission to establish baseline data . Foley catheter is usually inserted
Post op Care Vital signs are taken every 15 min for 1-2 hours or until stable. The condition of the incisional dressing, the fundas, and the amount of lochia are assessed. As well as IV intake and urinary output.Discharge is usually by third post op day.
Discharge teaching Contact HCP if temp exceeds 38 deg c, painful urination, lochia heavier than normal period, foul smelling lochia, wound separation, redness or oozing at incision site, severe abd pain.
Created by: bdrye01