Nursing Management of Labor and Birth at Risk

1. Nursing Management of Labor and Birth at Risk

2. Dystocia • Abnormal or difficult labor • Vast number of maternal and fetal factors • Problems with powers: hypertonic uterine dysfunction, hypotonic uterine dysfunction, precipitous labor • Problems with passenger: occiput posterior position, breech presentation, multifetal pregnancy, macrosomia and CPD, structural abnormalities • Problems with the passageway: pelvic contraction, obstructions in maternal birth canal • Problems with psyche: psychological distress

3. Dystocia (cont’d) • Nursing Assessment • History of risk factors • Vital signs • Uterine contractions • Fetal heart rate, fetal position • Nursing Management • Promoting labor progress • Providing physical and emotional comfort • Promoting empowerment

4. Preterm Labor • Regular uterine contractions with cervical effacement and dilation between 20 and 37 weeks’ gestation • One of most common obstetric complications • Therapeutic management • Risk prediction • Tocolytic drugs: magnesium sulfate, terbutaline, indomethacin, nifedipine • Corticosteroids • Antibiotic prophylaxis for women with group B streptococcus

5. Preterm Labor (cont’d) • Nursing Assessment • Risk factors • Subtle signs • Contraction pattern (4 contractions every 20 minutes or 8 contractions in 1 hour) • Laboratory and diagnostic testing: fetal fibronectin, cervical length via transvaginal ultrasound, salivary estriol, home uterine activity monitoring

6. Preterm Labor (cont’d) • Nursing Management • Tocolytic administration • Client education • Psychological support

7. Question Is the following statement True or False? Psychological stress in the woman can contribute to dystocia.

8. Answer True. Emotions such as fear, anxiety, helplessness, being alone, and weariness can lead to psychological stress, indirectly causing dystocia.

9. Postterm Labor • Pregnancy continuing past end of 42 weeks’ gestation • Unknown etiology • Maternal and fetal risks • Nursing Assessment: estimated date of birth; daily fetal movement counts, nonstress tests twice weekly, amniotic fluid analysis, weekly cervical examinations • Nursing Management: fetal surveillance; decision for labor induction; support; education, intrapartal care

10. Labor Induction and Augmentation • Induction: stimulating contractions via medical or surgical means; Augmentation: enhancing ineffective contractions after labor has begun • Indications • Therapeutic management • Cervical ripening (Bishop’s score): nonpharmacologic methods; mechanical methods; surgical methods; pharmacologic agents • Oxytocin

11. Labor Induction and Augmentation (cont’d) • Nursing Assessment • Relative indications; gestational age determination • Fetal status; maternal status; Bishop’s score • Nursing Management • Explanations • Oxytocin administration • Pain relief and support

12. Question Is the following statement True or False? Oxytocin is an important agent used to ripen the cervix for labor induction.

13. Answer False. Oxytocin is used to induce or augment labor once the cervix is ripe.

14. Intrauterine Fetal Demise • Numerous causes • Devastating effects on family and staff • Nursing Assessment • Inability to obtain fetal heart sounds • Ultrasound to confirm absence of fetal activity • Labor induction • Nursing Management • Assistance with grieving process • Referrals

15. Umbilical Cord Prolapse • Obstetric emergency • Pathophysiology: partial or total occlusion of cord with rapid fetal deterioration • Nursing Assessment • Prevention; risk factors • Continuous assessment of client and fetus • Nursing Management • Prompt recognition • Measures to relieve compression

16. Placental Abruption • Obstetric emergency involving premature separation • Risk factors • Management dependent on gestational age, extent of hemorrhage and maternal-fetal oxygenation perfusion • Maintenance of maternal cardiovascular status • Prompt delivery of fetus • Cesarean birth if fetus still alive; vaginal birth if fetal demise

17. Uterine Rupture • Obstetric emergency; onset marked by sudden fetal bradycardia • Nursing Assessment • Risk factors • Onset of sudden fetal distress; other signs • Nursing Management • Preparation for urgent cesarean birth • Continuous maternal and fetal monitoring

18. Amniotic Fluid Embolism • Obstetric emergency • Sudden onset of hypotension, hypoxia, and coagulopathy due to breakage in barrier between maternal circulation and amniotic fluid • Nursing Assessment: difficulty breathing, hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony with subsequent hemorrhage, ARDS, cardiac arrest • Nursing Management: supportive measures to maintain oxygenation and hemodynamic function and to correct coagulopathy; critical care monitoring

19. Question Which of the following assessment findings would lead the nurse to suspect an amniotic fluid embolism? • Respiratory distress • Hypertension • Acute abdominal pain • Sudden fetal distress

20. Answer A. Amniotic fluid embolism should be suspected in any pregnant woman with an acute onset of respiratory distress and hypotension. Sudden fetal distress and acute abdominal pain are associated with uterine rupture.

21. Amnioinfusion • Indications • Severe variable decelerations due to cord compression • Oligohydramnios due to placental insufficiency • Postmaturity or rupture of membranes • Preterm labor with premature rupture of membranes • Thick meconium fluid • Nursing management: teaching, maternal and fetal assessment, preparation for possible cesarean birth

22. Forceps- or Vacuum-Assisted Birth • Application of traction to fetal head • Indications: Prolonged second stage of labor, nonreassuring FHR pattern, failure of presenting part to fully rotate and descend, limited sensation or inability to push effectively, presumed fetal jeopardy or fetal distress, maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, infection • Risk of tissue trauma to mother and newborn. • Prevention as key

23. Cesarean Birth • Classic or low transverse incision • Major surgical procedure with accompanying risks • Nursing Assessment: history and physical examination for maternal and fetal indications • Nursing Management • Pre-operative care • Post-operative care

24. Question Is the following statement True or False? An amnioinfusion is appropriate for a pregnant woman experiencing a prolonged second stage of labor.

25. Answer False. Amnioinfusion is indicated for severe variable decelerations due to cord compression, oligohydramnios due to placental insufficiency, postmaturity or rupture of membranes, preterm labor with premature rupture of membranes, and thick meconium fluid. A forceps- or vacuum-assisted birth would be indicated for a prolonged second stage of labor.

26. Vaginal Birth After Cesarean (VBAC) • Controversy related to risk of uterine rupture and hemorrhage • Contraindications • Special areas of focus: consent, documentation, surveillance, and readiness for emergency • Nurses as advocates for clients; expertise in reading fetal monitoring tracings to identify nonreassuring pattern and instituting measures for emergency delivery