abnormal or difficult labor
-slow abnormal progression of labor
Hypertonic Uterine Dysfunction
occurs when the uterus never fully relaxes between contractions
-prolonged latent phase = stays at 2-3 cm and do NOT dilate as they should
Hypotonic Uterine Dysfunction
occurs during active labor; dilation more than 5-6 cm; when contractions become poor in quality and lack sufficient intensity to dilate and efface cervix
What factors are associated with Hypotonic Uterine Dysfunction?
Overstretching of the uterus Large fetus Multiple fetuses Hydramnios Multiple parity Bowel/bladder distention Excessive use of analgesia
What is the major risk with Hypotonic Uterine Dysfunction after birth?
Hemorrhage after giving birth because the uterus cannot contract effectively to compress blood vessels
refers to uterine contractions resulting in progressive dilation and effacement of cervix and accompanied by descent and expulsion of fetus
series of events including slower than normal rate if cervical dilation and delayed descent of fetus
complete cessation of progress
labor that is completes in less than 3 hours from the start of contractions to birth
Maternal Trauma from Precipitate Labor
- Cervical lacerations
- Uterine rupture
Potential Fetal complications from Precipitate Labor
Problems with Powers
Hypertonic uterine dysfunction Hypotonic uterine dysfunction Protracted disorders Arrest disorders Precipitate labor
Problems with Passenger
Occiput posterior position Breech presentation Multifetal pregnancy Macrosomia and CPD Structural abnormalities
Occiput Posterior Position
- Most common malposition
- Presents slightly larger diameters to the maternal pelvis first
External Cephalic Version
a procedure in which the fetus is rotated from breech to the cephalic presentation by manipulation through the mother’s abdominal wall
Buttocks or feet presenting first
obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered
twins, triplets, or more infants within a single pregnancy
What is the most common maternal complication with multifetal pregnancies?
Postpartum hemorrhage resulting from uterine atony
Newborn weighs 8.81-9.92 lbs or more at birth
-result of change in body composition w/ an increase in percentage of fat and fat mass
Macrosomia as been associated with what complications later in life?
Problems with Passageway
Obstructions in maternal birth canal
Contraction of the midpelvis is bad because it can cause what?
Arrest of fetal descent
Obstructions of Maternal Birth Canal
Swelling of soft maternal tissue and cervix
Termed soft tissue dystocia
Problems with Psyche
-fear, anxiety, helplessness, isolation, and weariness
Nursing Management for Dystocia
History of risk factors Maternal frame of mind Vital Signs Uterine contractions FHR, fetal position
Nursing Management for Dystocia
Promoting labor progress
Providing physical and emotional comfort
How often should you monitor the clients bladder for distention?
occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation
What is one of the most common obstetric complications?
When is predicting the risk of preterm labor valuable?
When there is an available intervention that is likely to improve the situation
No clear first-line drugs to manage preterm labor
-may prolong pregnancy for 2-7 days while steroids can be given for fetal lung maturity
Antibiotics should be reserved for what?
For group B streptococcal prophylaxis in women in whom birth is imminent
Why are Corticosteroids recommended for all pregnant women?
significantly reduce the incidence and severity of neonatal respiratory distress syndrome
When are corticosteroids recommended to be given?
A pregnant women between 24-34 weeks of gestation who are at risk of preterm birth within 7 days
Nursing Assessment of Preterm Labor
Laboratory and diagnostic testing
What are some signs of preterm labor?
- Change/increase in vaginal discharge
- Pelvic pressure
- Low-dull backache
- Menstrual like cramps
- UTI symptoms
- GI upset: N/V and diarrhea
- General sense of discomfort/unease
- Heaviness or aching in thighs
Labs/Diagnostic testing of Preterm Labor
CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length via transvaginal ultrasound, salivary estriol, home uterine activity monitoring
How early can a Fetal fibronectin test detect ROM?
1-2 weeks before
What medications are commonly used for Tocolytic administration?
What should you monitor for after administering Magnesium sulfate?
Flushing, N/V, dry mouth, lethargy, blurred vision, headache, and hypotension
Educating the Client Preterm
Harmful lifestyles Signs of genitourinary infections and preterm labor Appropriate response How to palpate and time contractions Importance of prenatal care
pregnancy that continues past the end of the 42 week of gestation
Postterm Labor Maternal Risks
Increased risk of cesarean birth Dystocia Birth trauma Postpartum Hemorrhage Infection
Postterm Labor Fetal Risks
Macrosomia Shoulder Dystocia Brachial plexus injuries Low APGAR scores Post-maturity syndrome Cephalopelvic disproportion
What can happen as amniotic fluid begins to decline after 38 weeks?
Oligohydramnios resulting in fetal hypoxia and an increased risk of cord compression
Hypoxia and Oligohydramnios predispose the fetus to what?
Aspiration of meconium
Nursing Assessment for Postterm Pregnancy
- Estimated date of birth
- Fetal movement counts
- Non-stress test twice weekly
- Amniotic fluid analysis
- Weekly cervical exams
- Client understanding
Nursing Management for Postterm Labor
Decision for labor induction
Intrauterine Fetal Demise (IUFD)
Fetal death that occurs after 20 weeks gestation, but before birth
Nursing Assessment of IUFD
Inability to obtain fetal heart sounds
Ultrasound to confirm absence of fetal activity
Nursing Management IUFD
Assistance w/ grieving process
What risks are considered obstetric emergencies?
- Umbilical cord prolapse
- Placental abruption
- Uterine rupture
- Amniotic fluid embolism
Umbilical Cord Prolapse
protrusion of the umbilical cord ahead of the presenting part of the fetus
What is key to managing umbilical cord prolapse?
Prevention by identifying clients at risk
What pregnancies would be considered most at risk for umbilical cord prolapse?
Malpresentation (breech) Growth restriction Prematurity ROM w/ fetus at high station Hydramnios Grandmultiparity Multiple gestations
What is often the first sign of umbilical cord prolapse?
Sudden fetal bradycardia or recurrent variable decelerations that become progressively more severe
Nursing Management for Umbilical Cord Prolapse
Measures to relieve compression
What measures would the nurse take to relieve compression of cord during umbilical cord prolapse?
- Call for help ASAP
- Do NOT leave mom
- Place sterile gloved hand into the vagina and holds the presenting part off the umbilical cord until delivery
What can you change mom’s position to during umbilical cord prolapse to help relieve compression?
- modified Sims (all 4’s)
- Knee-chest position
premature separation of a normally implanted placental from the maternal myometrium
What are the risk factors for Placental Abruption?
Preeclampsia Gestational hypertension Seizures Advanced maternal age Uterine rupture Uterine Trauma Smoking/Cocaine Coagulation defects Chorioamnionitis PROM Hydramnios
Management for Placental Abruption depends on what?
Extent of hemorrhage
Maternal-fetal oxygen perfusion
What is typically the main focus once diagnosis of Placental Abruption is confirmed?
Maintaining the cardiovascular status of mom
Developing plan to deliver fetus quickly
If the fetus is still alive during placental abruption what type of birth typically happens?
If Fetal Demise happens during placental abruption how will the mother give birth?
catastrophic tearing of the uterus at the site of previous scar into the abdominal cavity
The onset of Uterine Rupture is typically marked only by?
Sudden fetal bradycardia
How much time from diagnosis to delivery is there to still have a living baby?
Risk Factors of Uterine Rupture
Uterine scars Prior c/s Prior rupture Trauma Prior invasive molar pregnancy History of placental percreta or increta Congenital uterine anomalies Multiparity Previous uterine myomectomy Malpresentation Cocaine use Labor induction w/ excessive uterine stimulation
What is the first and most reliable symptom of uterine rupture?
Sudden fetal distress
Signs of Uterine Rupture
Sudden fetal distress
Acute-continuous abdominal pain w/ or w/o epidural
Irregular abdominal wall contour
Loss of station in fetal presenting part
Hypovolemic shock of women, baby, or both
Nursing Management of Uterine Rupture
Prepare for urgent c/s
Continuous maternal and fetal monitoring
Hypotension and tachycardia may indicate what?
Amniotic Fluid Embolism
amniotic fluid containing particles of debris enters the maternal circulation and obstructs the pulmonary vessels causing respiratory distress and circulatory collapse
Amniotic Fluid Embolisms are characterized by what?
Sudden onset of hypotension, hypoxia, and coagulopathy
Amniotic Fluid Embolism causes what?
Respiratory distress and circulatory collapse
What are some predisposing factors for Amniotic Fluid Embolism?
Placental Abruption Uterine over distention Fetal demise Uterine trauma Oxytocin-stimulated labor Amnioinfusion Multi-parity Advanced maternal age ROM
Signs/Symptoms of Amniotic Fluid Embolism
Difficulty breathing Hypotension Cyanosis Hypoxemia Uterine atony w/ or w/o subsequent hemorrhage seizures tachycardia coagulation failure DIC Pulmonary edema ARDS Cardiac arrest
Upon recognition of Amniotic Fluid Embolism what supportive measures should be implemented?
- maintain oxygenation and circulation function
- Correct and control hemorrhage and coagulopathy
How would you manage DIC if it was to occur?
replacement with packed red blood cells or fresh frozen plasma
What can be used to address uterine atony?
Oxytocin infusions and prostaglandin analogs
stimulation of uterine contractions by medical or surgical means before the onset of spontaneous labor
What is the most common reason to have labor induced?
Indications for Labor Induction
Prolonged gestation PPROM Gestation hypertension Cardiac or Renal disease Chorioamnionitis Dystocia Intrauterine fetal demise Isoimmunization Diabetes
A Bishop score less than 6 typically indicates what?
Indicates that a cervical ripening method should be used prior to induction
What does a Bishop score greater than 8 indicate?
A successful vaginal birth
Most commonly used scoring system to determine cervical ripeness
-indicates who is likely to have a successful induction
What herbal agents are believed to induce labor?
Cabbage leaves Evening primrose oil Black haw Black and blue cohosh Red raspberry leaves
What home remedies are believed to induce labor?
Castor oil, hot baths, enemas, sexual intercourse with breast stimulation
How can sexual intercourse induce labor?
Promotes the release of oxytocin which stimulates uterine contractions
Human semen is a biologic source of prostaglandins
What are the risks of using mechanical methods of induction?
Mechanism of action for Mechanical method of induction
Application of local pressure stimulates the release of prostaglandins to ripen the cervix
Advantages of Mechanical Methods
Simplicity or preservation of the cervical tissue or structure, lower cost, and fewer side effects
enhancing ineffective contractions after labor has begun
What are the 2 surgical methods of inducing labor?
Stripping of membranes
Stripping of Membranes
inserting a finger through the internal cervical os and moving in circular direction causing membranes to detach
inserting cervical hook through the cervical os to deliberately rupture the membranes
What will an amniotomy promote?
Pressure of the presenting part on the cervix and stimulating an increase in the activity of prostaglandins
What are the risks associated with Surgical methods of induction?
Umbilical cord prolapse or compression Maternal or neonatal infections FHR decelerations Bleeding Client discomfort
What should be monitored closely after surgical induction?
FHR pattern and amniotic fluid characteristics
What are the 2 pharmacological agents used to induce labor?
Prostaglandin analogs and Oxytocin
Advantages of using prostaglandins to induce labor:
Promotes both cervical ripening and uterine contractility
What is the disadvantage of using prostaglandins?
Their ability to induce excessive uterine contractions which can increase maternal and perinatal morbidity
What Prostaglandin analogs are often used for induction?
Prepidil, Cervidil, Cytotec
used to stimulate uterine contractions
What is typically done before oxytocin is introduced?
Cervical ripening is initiated before oxytocin by using a prostaglandin analog
What is the most common effect of oxytocin?
Uterine hyperstimulation leading to fetal compromise and impaired oxygenation
What other type of effect does oxytocin have on the body?
Antidiuretic effect resulting in decreased urine flow that may lead to water intoxication
What symptoms should be watched for with water intoxication?
Headaches and vomiting
Side effects of Oxytocin
Nursing Assessment for Induction/Augmentation
- Review history for relative indications for induction/augmentation
- Assist w/ determining gestational age
- Assess fetal and maternal status
- Bishop Score
a volume of warmed, sterile normal saline or LR is introduced into the uterus transcervically through an intrauterine pressure catheter
What is an Amnioinfusion typically indicated for?
- Severe variable decelerations due to cord compression
- Oligohydramnios due to placental insufficiency
- Post-maturity or ROM
- Preterm labor w/ PROM
- Thick meconium fluid
Nursing Management for Amnioinfusion
Maternal and fetal assessment
Prep for possible c/s
cup-shaped instrument attached to a suction pump used for the extraction of the fetal head
What part of the fetal head is the vacuum extractor applied to?
stainless steel instruments with rounded edges that fit around the fetal head
When is the use of the vacuum extractor/forceps indicated?
Prolonged second stage of labor, non-reassuring FHR pattern, failure of presenting part to fully rotate and descend, limited sensation or inability to push effectively, fetal distress, maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, infection
What are the risks of using vacuum/forceps?
Risk of tissue trauma to mom and baby
Maternal trauma from Vacuum/forceps
lacerations of cervix, vagina, or perineum
extension of episiotomy incision into the anus
Newborn trauma from vacuum/forceps
ecchymoses facial and scalp lacerations facial nerve injury cephalhematoma caput succedaneum
What can be done to try and prevent the use of vacuum/forceps?
Frequent position changes
Ambulation if permitted
Frequent reminding to empty bladder
Providing adequate hydration
surgical birth of the fetus through an incision in the abdomen and uterine wall
-classic (vertical) or low transverse (horizontal)
Which c/s incision is more common today?
Risks from c/s
infection hemorrhage aspiration pulmonary embolism urinary tract trauma thrombophlebitis paralytic ileus atelectasis fetal injury and transient tachypnea
Nursing Assessment for C/S
History and physical exam for maternal and fetal indications
Preoperative care for C/S
- Ascertain family understanding of procedure
- Explain what to expect postop
- Explain incentive spirometer and leg exercises
- Prep surgical site
- Start IV fluids; foley catheter
- Administer any preop meds
Postoperative care for C/S
- Vitals/ Lochia flow
- Perineal care
- Assess abdominal dressing
- Assess uterine tone
- Assess woman’s LOC
- Assess for evidence of abdominal distention and auscultate bowel sounds
- Early ambulation
- Cough, deep breathing, incentive spirometer
- Encourage bonding
Vaginal Birth after C/S (VBAC)
a women who gives birth vaginally after having at least one previous c/s
Contraindications for VBAC
- prior uterine incision
- prior uterine surgery
- uterine scar
- contracted pelvis
- inadequate staff/facility
Special areas of focus for VBAC
Readiness for emergency