Chapter 14: Caring for the Woman Experiencing Complications During Labor and Birth Flashcards
Dystocia
long, difficult, or abnormal labor, is a term used to identify poor labor progression
>may be related to maternal positioning during labor, fetal malpresentation, anomalies, macrosomia, and multiple gestation
Recognizing Indicators of Dystocia
nurses should suspect dystocia when there is a lack of progress in the rate of cervical dilation, fetal descent and expulsion, or an alteration in the pattern of normal uterine contractions
Factors Associated with an Increased risk of Uterine Dystocia
- uterine abnormalities, such as congenital malformations and overdistension (e.g. hydramnios and multiple gestation)
- fetal malpresentation or malposition
- cephalopelvic disproportion (CPD)
- maternal body build (greater than 30 lb overweight, short stature)
- uterine overstimulation with oxytocin
- inappropriate timing of analgesic/anesthetic agents
- maternal fear, fatigue, dehydration, electrolyte imbalance
Hypertonic Labor
contractions are strong and often painful but are ineffective in producing cervical effacement and dilation
>an increase in catecholamine release (e.g. epinephrine and norepinephrine) can result in poor uterine contractility
>uterine pacemakers (the energy source of contractions located in the uterine wall) do not initiate a good myometrial response needed for progressive cervical change; instead, irregular spasmodic episodes occur that do not result in effective contractions or assist in bringing the fetus into a more favorable downward position
What causes hypertonic labor?
-maternal anxiety; anxiety produces high levels of catecholamines
>many factors contribute to a woman’s fear: primiparous labor, loss of control, sexual abuse, lack of support, cultural differences, fear of pain
-occiput-posterior malposition of the fetus can be a cause
Management of Hypertonic Labor
-establish a more effective labor pattern
-rest, hydration, and sedation reduce the irritability of the uterus and help to diminish the ineffective contractions
-medications for rest: meperidine (Demerol), hydromorphone (Dilaudid), and morphine
-non-pharmacological techniques to reduce anxiety: relaxation techniques, massage, warm shower or rub bath, and emotional support
>whose fetus is in a occiput-posterior position: facilitate the head into a more favorable position; walk and change positions during course of labor (want an anterior lie for the fetus)
Nursing Care For Hypertonic Labor
- thorough assessment; identify factors that contribute to increased maternal anxiety
- monitoring of contractions
Hypotonic Labor
uterine contractions decrease in frequency and intensity
- hypotonia
- occurs during active phase of labor
- fewer than 2 or 3 contractions during a 10 minute period
- uterus can be easily indented, even at the peak of the contraction, and the intrauterine pressure (IUP) is insufficient for the progression of cervical effacement and dilation
How does Hypotonic labor happen?
maternal and fetal factors that produce excessive uterine stretching and overdistention
>fetal macrosomia, anomalies, malpresentation, multiple gestation, and hydramnios
Fetal Macrosomia
leading cause of uterine hypotonia
-fetus whose birth weight is above the 90th percentile on an intrauterine growth chart for that gestational age
Risks for Uterine Hypotonia
- fetal macrosomia
- maternal obesity
- pharmacological agents used to alleviate pain
How is Labor hypotonia managed?
- clinical, ongoing assessments
- walking and position changes
- use of relaxation techniques, massage, and water treatments can decrease need for pharmacological agents for pain
- an amniotomy, or artificial rupture of membranes may be successful in increasing uterine contractility
- other measures to enhance progress of labor: membrane stripping, nipple stimulation, and oxytocin infusion
- maternal and fetal assessments: vital signs, contraction patterns, and cervical changes documented
Precipitous Labor
produce very rapid, intense contractions
-lasts less than 3 hours from the beginning of contractions to birth
>greatest risk: multiparous women with little soft tissue resistance
-patients often progress through the first stage of labor with little or no pain and may present to the birth setting already advanced into the second stage
Complications of a Precipitous Labor
result from trauma to maternal tissue and to the fetus because of the rapid descent
-hemorrhage may occur from uterine rupture and vaginal lacerations
>most women are not prepared for the rapid advancement of labor and become alarmed, highly anxious, and fearful
>fetus may suffer from hypoxia related to the decreased periods of uterine relaxation between the contractions and intracranial hemorrhage r/t the rapid birth
Nursing Considerations for a Precipitous Labor
-initial assessments
-a multiparous patient with a previous history of rapid labors needs to alert physician or midwife; prenatal record should include this
-in a nulliparous patient, careful examination for cervical dilation and effacement is required
>because a previous labor pattern is an unknown variable in a nulliparous patient, the nurse must be alert in recognizing signs of abnormally rapid cervical dilation
The nurse who assists with a precipitous birth should take the following actions
- request a translator to interpret for patients unable to speak or understand English
- assist the laboring woman to breathe through each contraction to prevent pushing
- provide continuous emotional support
- provide perineal support with warm cloths
- frequently monitor the maternal and fetal vital signs and immediately report any abnormal findings to physician or certified midwife
- after birth, carefully monitor for signs of hemorrhage; assess for trauma to the perineum
- assess neonate for evidence of trauma and report and document all findings
Pelvic Dystocia
occurs when contractures (fixed tightening) of the pelvic diameters reduce the capacity of the bony pelvis, the mid-pelvis, the outlet, or any combination of these planes
-contractures of the maternal pelvis may result from malnutrition, neoplasms, congenital abnormalities, traumatic spinal injury, or spinal disorders
-immaturity of the pelvis may predispose adolescent mothers to pelvic dystocia
>contractures of the inlet, midplane, or outlet can cause interference in engagement and fetal descent, necessitating a cesarean birth
Soft Tissue Dystocia
occurs when the birth passage is obstructed by an anatomical abnormality other than that involving the bony pelvis
-the obstruction, which prevents the fetus from entering the bony pelvis, may be caused by placenta previa, uterine fibroid tumors (leiomyomas), ovarian tumors, or a full bladder or rectum
>Bandl ring; late sign associated with obstructed labor
Bandl ring
a pathological retraction ring that develops between the upper and lower uterine segments
- is the abnormal junction between the two segments of the human uterus
- associated with prolonged labor, prolonged rupture of the membranes, and an increased risk of uterine rupture
- late sign associated with an obstructed labor
Trial of Labor (TOL)
the surveillance of a woman and her fetus for a set amount of time (usually 4 to 6 hours) during spontaneous active labor to assess the safety of a vaginal birth
->indications for a trial of labor: situations when the maternal pelvis is of questionable size or shape, fetus is in an abnormal presentation, and when the woman decides to have a vaginal birth after a previous (low segment transverse) cesarean birth
What happens before a trial of labor (TOL)?
an assessment of the adequacy of the maternal pelvis for vaginal birth (to rule out cephalopelvic disproportion (CPD)) is conducted with sonography or maternal pelvimetry
>cervix must be favorable (soft, dilatable), and throughout the TOL, the woman is assessed for the presence of adequate contractions, engagement an descent of the fetal presenting part, and cervical dilation and effacement
Nursing Responsibilities during a Trial of Labor (TOL)
- assessment of maternal vital signs and FHR pattern
- if complications arise, notify primary care provider, and evaluates and documents the maternal-fetal responses to the interventions
- offer support and encouragement; ongoing information about labor progress
Amnioinfusion
instillation of normal saline or lactated ringers solution into the uterine cavity
-used to supplement the amniotic fluid volume in patients with oligohydramnios caused by uteroplacental insufficiency, premature rupture of membranes, and postmaturity
>patients experiencing variable FHR decelerations caused by cord compressions is improved through use of Amnioinfusion
>risks of procedure: infection, overdistention of the uterus, and increased uterine tone
How is Amnioinfusion Performed?
the fluid is instilled through an intrauterine pressure catheter (IUPC); the amniotic membranes must be ruptured for catheter placement
- fluid may be warmed with a blood warmer before administration and the infusion may be given by bolus or continuous flow
- when possible, a double lumen IUPC is used because the intrauterine pressure can be monitored without stopping the Amnioinfusion
Nursing Considerations for a Amnioinfusion
- careful monitoring of the infusion, the intensity and frequency of uterine contractions, and the maternal vital signs
- some may sign an informed consent before intervention
- educate the woman and her support person regarding the infusion ad its purpose
- document amount of solution infused and presence of any vaginal discharge
When caring for a patient undergoing Amnioinfusion, the nurse must:
- assess the patient’s response to the fluid infusion
- continually monitor the frequency and intensity of uterine contractions
- stop the infusion if the following signs and symptoms are noted: maternal shortness of breath, an overdistended uterus, hypotension, or tachycardia
Amniotomy
artificial rupture of membranes (AROM), is a nonpharmacological intervention that may be done to augment or induce labor or to facilitate the placement of internal monitors during labor
How is AROM performed? (amniotomy, artificial rupture of mebranes)
insertion of an Amnihook or other sharp instrument into the lower segment of the fetal membrane; following rupture, the fluid is allowed to drain slowly
>the rupture of the membranes causes a release of arachidonic acid, which converts to prostaglandins, known inducers of labor through the stimulation of oxytocin in the uterus
>labor usually happens within 12 hours after artificial rupture
-if not, there’s an increased risk of infection; or fetal injury and umbilical cord prolapse
>because of risk for infection; amniotomy is used with oxytocin induction to facilitate delivery
Nurses role for amniotomy
-vital signs, cervical effacement and dilation, station of the presenting part, FHR, and contractions are documented
-the presenting part must be engaged and well applied to the cervix to prevent umbilical cord prolapse (protrusion of the umbilical cord in advance of the presenting part)
>there should be no evidence of active infection of the genital tract (e.g. herpes) or HIV infection
Preparing For an Amniotomy
-provides information, assesses woman’s understanding of the procedure, and assures it will be painless to her and her fetus although she may experience discomfort when the instrument is inserted through the vagina and cervix
-necessary equipment assembled: sterile gloves, lubricant, and the Amnihook or Allis clamp
-place hip pads under buttocks to absorb fluid
-positions woman on a padded bedpan or with rolled up linens to elevate hips
>unwrap and pass equipment
What happens after an Amniotomy
after the rupture, the nurse notes and record FHR and pattern
-color, odor, consistency, and clarity (and amount, if unusual) of the amniotic fluid are documented
-document time of rupture and the indication for the amniotomy
-patient may request analgesia or epidural anesthesia before the procedure
>if not requested medications, nurse assists with relaxation and breathing techniques during the contractions following the amniotomy because they are likely to be stronger
-perform a vaginal exam to palpate for umbilical cord, and determine fetal station and presentation
-maternal temperature assessed frequently (q 2 hours) to rule out infection (tempt > 100.4, chills, uterine tenderness on palpation, foul smelling vaginal discharge, and fetal tachycardia)
Induction of Labor
the use of chemical or mechanical modalities to initiate uterine contractions (before their spontaneous onset) to bring about childbirth
Indications for Induction
considered when either a maternal or fetal condition exists that dictates the need for medical intervention in the labor process
- post term pregnancy
- maternal medical conditions (e.g. diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, or antiphospholipid syndrome)
- gestational hypertension
- fetal demise
- chorioamnionitis
- premature rupture of membranes
- fetal compromise (e.g. severe fetal growth restriction, isoimmunization, or oligohydramnios)
- preeclampsia, eclampsia
Bishop Score
rating system that may be used to determine the level of cervical inducibility
- series of points is awarded to cervical dilation, effacement, station, consistency, and position
- labor induction more successful with a higher score (9 or more for nulliparous, and % or more for multiparous)
Cervical Ripening Agents
if the cervix is not favorable for oxytocin induction, a chemical cervical ripening agent may be prescribed
>prostaglandin E1 (PGE1) (Misoprostol)
>prostaglandin E2 (PGE2) (Dinoprostone)
Cervical Ripening Agent: Prostaglandin E1 Misoprostol (Cytotec)
ripens the cervix (causes softening and initiates dilation and effacement); stimulates uterine contractions
-used for both cervical ripening and induction of labor
-Adverse effects: diarrhea, nausea and vomiting, headaches, fever, tachysystole (> 5 uterine contractions in 10 minutes over a 30 minute window without alteration of FHR or pattern), uterine hyperstimulation (tachysystole with non-reassuring FHR or patterns), fetal passage of meconium
-intravaginally, orally, or sublingually
>at least 4 hours after last dose, oxytocin may be given for the induction of labor if cervical ripening has occurred and labor has not begun
Cervical Ripening Agent: Prostaglandin E2 Dinoprostone (Cervidil)
ripens the cervix (causes softening and initiates dilation and effacement); stimulates uterine contractions
-Adverse Effects: diarrhea, nausea and vomiting, headache, back pain, fever, hypotension, tachysystole (> 5 uterine contractions in 10 minutes averaged over a 30 minute window without alteration in FHR or pattern), uterine hyperstimulation (tachysystole with non-reassuring fetal heart rate or patterns), fetal passage of meconium
>Dinoprostone vaginal gel (Prepidil and Prostin E2) or Dinoprostone vaginal insert (Cervidil); vaginal insert releases prostaglandins at a slower rate than the gel
>used when bishop score is 4 or less
>uterine contractions begin 5 to 7 hours after administration
>induction with oxytocin can be initiated 30 to 60 minutes after removal of vaginal insert
>when using gel, oxytocin must be delayed until 6 to 12 hours after last instillation of medication
>Cervidil advantage; can be removed if uterine tachysystole occurs
When Cervical Ripening Agents Are administered
-prior to administration, explains the procedure, ensures informed consent has been obtained, and asks patient to void
-maternal vital signs and FHR and pattern are assessed before each medication administration and periodically throughout according to protocol
-after placement of medication, nurse assists woman to maintain a supine position with lateral tilt or a side lying position (30 to 40 minutes after misoprostol; 30 to 60 minutes after Dinoprostone gel; 2 hours after placement of Dinoprostone insert)
>in the advent of adverse effects, nurse uses saline-soaked gauze wrapped around the fingers to swab the vagina (or grasps pull string attached to insert) to remove remaining medication and prepares to administer terbutaline subQ or intravenously
Oxytocin
hormone produced by the pituitary gland , stimulates uterine contractions
-used to induce labor or augment a labor that is progressing slowly because of ineffective uterine contractions
Safe administration of Oxytocin
- explanation and assessment of patients level of understanding
- position woman to a side-lying or upright position
- assessment of patient and fetus is conducted and documented
- solution is prepared and administered via pump delivery system; the piggyback solution is flagged with a medication label and connected to the intravenous infusion at the port nearest the point of venous insertion
- medication administered as ordered; ongoing assessments according to protocol
- documents the medication (kind, amount, time of beginning of infusion, increasing the dose, maintaining the dose, and discontinuing the infusion)
- documents maternal-fetal reactions (FHR and pattern, maternal vital signs, pattern and progress of labor, nursing interventions, and maternal response) and when notification of primary health-care provider takes place
Signs of Uterine Hyperstimulation
-uterine contractions that last greater than 90 seconds and occur more frequently than every 2 minutes
-uterine resting tone greater than 20 to 25 mm Hg with a peak pressure greater than 80 mm Hg
-non-reassuring FHR and pattern (baseline less than 100 or greater than 160 bpm; absent variability; repeated late decelerations or prolonged decelerations
(with more frequent contractions there is less relaxation time for the fetus to get oxygen)
What does Uterine Tachysystole cause?
reduced blood flow through the placenta and results in FHR decelerations, fetal asphyxia, and neonatal hypoxia
Contraindications to the use of oxytocin to stimulate labor
- vasa previa or complete placenta previa
- transverse fetal lie
- umbilical cord prolapse
- previous classical cesarean delivery
- active genital herpes infection
- previous myomectomy (surgical excision of a fibroid) entering the endometrial cavity
Conditions that necessitate special precaution during oxytocin administration
- breech presentation
- multifetal pregnancy
- presenting part above the pelvic inlet
- severe hypertension
- maternal heart disease
- polyhydramnios
- one or more previous low transverse cesarean deliveries
- abnormal FHR patterns not necessitating emergent delivery
Augmentation of Labor
used to stimulate uterine contractions after labor has begun spontaneously but is not progressing satisfactorily
>management of hypotonic uterine dysfunction
>accomplished with amniotomy, oxytocin infusion, and nipple stimulation
>noninvasive approaches include: ambulation, hydration, relaxation, and hydrotherapy (attempt this before invasive measures)
Nursing Responsibilities during labor induction or augmentation
-obtaining informed consent for the procedure after physician explanation
-monitoring of the labor
>following should be placed on a flowsheet:
-vital signs (BP, pulse, and respirations q 30 to 60 minutes and with every increment in medication dose)
-FHR (electronic monitoring)
-frequency, duration, and strength of contractions (note contraction pattern and uterine resting tone q 15 minutes and with very increment in medication dose during first stage; then monitor q 5 minutes during second stage)
-cervical effacement and dilation
-fetal station and lie
-rate of oxytocin infusion
-intake and urine output (limit IV intake to 1000 mL/8 hr.; output should be 120 mL or more every 4 hours)
-any untoward effect of the medication administration (nausea, vomiting, headache, or hypotension)
-psychological response to the patient
Recognizing and Responding to Problems During Labor Induction with Oxytocin
-1:1 nurse-to-patient ratio
-nurse remains alert to signs indicative of complications; uterine tachysystole, especially coupled with non-reassuring FHR pattern, and suspected uterine rupture
>management of tachysystole: efforts to reduce uterine activity to minimize the risk of evolving fetal hypoxemia or acidemia
>immediate emergency measures: discontinuing oxytocin per protocol, positioning patient on her side, IV fluid bolus and/or increasing the primary IV rate up to 200 ml/hr. (unless evidence of water intoxication–in this situation, the rate is decreased to one that keeps the veins open), administering oxygen by face mask at 8 to 10 L/min per order or protocol, and preparing to administer tocolytic medications (e.g. terbutaline) per order or protocol
