High Risk Labor and Birth- 10 Flashcards
Dystocia
difficult labor that is characterized by abnormally slow labor progress
Hypertonic uterine dysfunction
uncoordinated uterine activity
Contractions are frequent and painful but ineffective in promoting dilation and effacement.
Risk factors for dystocia
● Congenital uterine abnormalities such as bicornate uterus.
● Malpresentation of the fetus such as occiput posterior, or face presentation.
● Cephalopelvic disproportion.
● Tachysystole of the uterus with oxytocin.
● Maternal fatigue and dehydration.
● Administration of analgesia or anesthesia early in labor.
● Extreme maternal fear or exhaustion, which can result in catecholamine release interfering with uterine contractility.
Hypertonic uterine dysfunction risk factor
Nulliparous women
Hypertonic uterine dysfunction s/s
●Painful, frequent UCs with inadequate uterine relaxation between UCs with little cervical changes
● May be Category II (indeterminate) or Category III (abnormal) fetal heart rate (FHR) related to prolonged labor and inadequate uterine relaxation
Hypotonic uterine dysfunction
when the pressure of the UC is insufficient to promote cervical dilation and effacement.
Hypotonic uterine dysfunction risk factors
● Multiparous women
● Extreme fear
Hypotonic uterine dysfunction s/s
● Decreased frequency, strength, and duration of UCs
● Little or no cervical change
● Increased fear and anxiety levels
First-Stage Arrest: Spontaneous labor
greater than 6 cm dilation with membrane rupture and more than 4 hours of adequate contractions or more than 6 hours if contractions are inadequate with no cervical change
Induced labor:
greater than 6 cm dilation with membrane rupture or greater than 5 cm without membrane rupture and more than 4 hours of adequate contractions, or more than 6 hours if contractions are inadequate with no cervical change
Second-Stage Arrest
No progress for 4 hours or more in nulliparous women with an epidural
3 hours or more in nulliparous women without an epidural
3 hours or more in multiparous women with an epidural
2 hours or more in multiparous women without an epidural
Second-Stage Arrest s/s
● Inadequate or ineffective pushing with little or no descent of the fetal head with expulsive pushing efforts
● Potential for Category II (indeterminate) or Category III (abnormal) FHR
Second-Stage Arrest risk
● Maternal exhaustion
● Epidural anesthesia because woman may not feel the urge to push
Precipitous labor
labor lasting fewer than 3 hours from onset of labor to birth.
Precipitous labor risk factors
● Grand multiparity
● History of precipitous labor
Precipitous labor s/s
● Hypertonic UCs (tetanic UCs) occurring every 2 minutes or more frequently, lasting greater than 60 seconds and strong
● Rapid cervical dilation such that labor is less than 3 hours.
● Potential for Category II (indeterminate) or Category III (abnormal) FHR and nursing actions are based on FHR pattern
Fetal dystocia
Baby is not in the right position for birth
caused by excessive fetal size, malpresentation, multifetal pregnancy, or fetal anomalies.
Fetal dystocia s/s
● FHR may be heard above the umbilicus versus in the lower uterine segment; this is a sign that the fetus may be in position other than vertex.
● The SVE reveals buttocks or face when malpresentation is the cause of dystocia.
● The presenting part is not engaged in the maternal pelvis.
● There is no fetal descent through the pelvis.
Fetal dystocia risk factor
● Contraction or narrowing of the pelvic inlet, the midpelvis, or the pelvic outlet
● Abnormal fetal presentation or position such as asynclitism, face, brow presentation, or breech or transverse lie
● Fetal anomalies, such as hydrocephalus, and/or any other fetal anomaly that interferes with fetal descent through the birth canal
Pelvic dystocia
the contraction of one or more of the three planes of the pelvis.
Pelvic dystocia risk factors
● Small pelvis
● Abnormal pelvic shape
Induction of labor
deliberate stimulation of UCs before the onset of spontaneous labor to facilitate a vaginal delivery
If done for nonmusical reasons it should be done after 39 weeks
Before elective induction of labor fetal maturity must be confirmed to be 39 weeks or greater by:
- Ultrasound before 20 weeks’ gestation confirms gestational age of 39 weeks or greater.
- Fetal heart tones have been documented as present by Doppler for 30 weeks.
- It has been 36 weeks since a positive serum or urine pregnancy test was confirmed.
Medical reasons for induction of labor
● Abruptio placentae
● Chorioamnionitis (intraamniotic infection)
● Fetal demise
● Gestational hypertension
● Preeclampsia, eclampsia
● Premature rupture of membranes
● Post-term pregnancy
● Maternal medical conditions
● Fetal compromise
Mistimed cervical ripening and induction can lead to what
unplanned iatrogenic preterm birth, and recent evidence documents increased neonatal morbidity in babies born prior to 39 weeks’ gestation but after 37 weeks’ gestation
Oxytocin Induction
A pharmacological method for labor induction
Nurses role in administering oxytocin in labor- titration
decreasing the dosage rate or discontinuing the medication when contractions are too frequent, discontinuing the medication when fetal status is indeterminate or abnormal, and increasing the dosage rate when uterine activity and labor progress are inadequate.
Once active labor is established, oxytocin should be discontinued
Oxytocin high alert medication- requirements
- Requirement that women having elective labor induction be at least 39 completed weeks’ gestation
- Standard order sets and protocols that reflect a standardized clinical approach to labor induction and augmentation based on current pharmacological and physiological evidence
- Standard concentration of oxytocin prepared by the pharmacy
- Standard definition of uterine tachysystole that does not include a Category III or II (abnormal or indeterminate) FHR pattern (a contraction frequency of more than five in 10 minutes, a series of single contractions lasting 2 minutes or more, contractions of normal duration occurring within 1 minute of each other)
- Standard treatment of oxytocin-induced uterine tachysystole guided by fetal status
Tachysystole
excessive uterine activity and can be either spontaneous or induced
more than five contractions in 10 minutes, averaged over 30 minutes
Nursing actions for tachysystole with Category I (normal) FHR pattern
- Maternal repositioning (left or right lateral)
- IV fluid bolus of at least 500 mL lactated Ringer’s (unless contraindicated)
- Oxygen 10 L/min via nonrebreather mask
- If uterine activity has not returned to normal after 10 to 15 minutes, decrease oxytocin rate by at least half; if uterine activity has not returned to normal after 10 to 15 more minutes, discontinue oxytocin until uterine activity is normal.
Nursing actions for tachysystole with a Category II (indeterminate) or Category III (abnormal) FHR pattern
- Discontinuing oxytocin and notifying the provider.
- Maternal repositioning (left or right lateral).
- Administering IV fluid bolus of at least 500 mL lactated Ringer’s (unless contraindicated).
- Giving O2 at 10 L/min by nonrebreather mask.
- Notifying provider of actions taken and maternal-fetal response.
- With category III FHR pattern request an immediate bedside evaluation.
- Considering terbutaline if no response to above measures.
Cervical ripening
process of physical softening, thinning, and dilating of the cervix in preparation for labor and birth
begins prior to the onset of labor contractions and is necessary for cervical dilation
Bishop score
greater than 8 considered to indicate a favorable cervix
6 or less has been used to denote an unfavorable cervix
Mechanical cervical ripening
devices that are inserted through the vagina and into the cervix to promote cervical dilation
pharmacological prostaglandins have partially replaced mechanical methods
Hygroscopic dilators
Several dilators are inserted into the cervix—as many as will fit—and they expand over 12 to 24 hours as they absorb water.
Balloon catheters
30-mL to 50-mL Foley catheter filled with saline is effective in inducing cervical ripening and dilation.
Risks of inductions- oxytocin
●Tachysystole
● Failed induction of labor
●tachysystole and subsequent FHR decelerations are common side effects
● Water intoxication can occur with high concentrations of oxytocin with large quantities of hypotonic solutions
Risks Associated With Mechanical Cervical Ripening
● Higher infection rate
● Premature rupture of membranes (PROM)
When we do mechanical cervical ripening
● When the woman has little or no cervical effacement
● When pharmacological methods are contraindicated, such as women with prior uterine incision
Risks Associated With Pharmacological Methods of Cervical Ripening
● Tachysystole of the uterus
Pharmacological methods of cervical ripening
variety of hormonal preparations placed in or near the cervix, produce cervical ripening by causing softening and thinning of the cervix
Sweeping or stripping the membranes
digital separation of the chorionic membrane from the wall of the cervix and lower uterine segment during a vaginal exam done by a primary care provider to stimulate labor.
Risks Associated With Membrane Sweeping
● Infection
● Bleeding from undiagnosed placental problem
● Unplanned ROM
Amniotomy
artificial rupture of membranes (AROM) to induce or augment labor with an amnihook during a SVE
Risks Associated With Amniotomy
● Severe variable decelerations
● Bleeding from undiagnosed vasa previa or other placental abnormality
● Umbilical cord prolapse when presenting part is not engaged
● Intraamniotic infection increases with duration of the rupture.
External cephalic version (ECV)
the fetus is rotated from the breech to the cephalic presentation by manipulation through the mother’s abdomen
Risks Associated With ECV
● Severe variable decelerations
● Umbilical cord compression
Augmentation of labor
stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus
usually with oxytocin
Risks Associated With Augmentation
● Tachysystole leading to a Category II or Category III FHR pattern is a primary complication of oxytocin in labor
Complementary Therapies to Stimulate Labor
Herbal preparations: ● Black cohosh ● Blue cohosh ● Evening primrose oil ● Raspberry leaves may be taken orally to promote prostaglandin or oxytocin production.
Sexual intercourse:
● Semen contains prostaglandin to open the cervix, and orgasm may be associated with prostaglandin and oxytocin release.
Operative vaginal delivery
vaginal birth that is assisted by vacuum extraction or forceps
Vacuum-assisted delivery
birth involving the use of a vacuum cup on the fetal head to assist with delivery of the head
Vacuum-assisted delivery why
● Suspicion of immediate or potential fetal compromise
● Need to shorten the second stage for maternal benefit
● Prolonged second stage
Vacuum-assisted delivery risk mom
● Vaginal and cervical lacerations
● Extension of episiotomy
● Hemorrhage related to uterine atony, uterine rupture
● Bladder trauma
● Perineal wound infection
Vacuum-assisted delivery risk baby
● Intracranial hemorrhage and retinal hemorrhage
● Cephalohematoma (15%) and therefore increased risk of jaundice
● Scalp lacerations or bruising (10%)
Cephalohematoma
collection of blood between a baby’s scalp and the skull.
Forceps-assisted birth
an instrument is used to assist with delivery of the fetal head, typically done to improve the health of the woman or the fetus.
Forceps-assisted birth why
● The fetal head engaged and the cervix is completely dilated.
● There is suspicion of immediate or potential fetal compromise.
● To shorten the second stage for maternal benefit
● Prolonged second stage
● High level of regional anesthesia that inhibits pushing
Forceps-assisted birth risk mom
● Vaginal and cervical lacerations
● Extension of episiotomy
● Hemorrhage related to uterine atony, uterine rupture
● Perineal hematoma
● Bladder trauma
● Perineal wound infection
Forceps-assisted birth risk baby
● Cephalohematoma
● Nerve injuries, including craniofacial and brachial plexus injuries
● Skin lacerations or bruising
● Skull fractures
● Intracranial hemorrhage
Vaginal Birth After a Cesarean (VBAC) Benefits
shorter recovery time and overall lower morbidity and mortality, including less blood loss, fewer infections, and fewer thromboembolic problems
TOLAC
planned attempt to labor by a woman who has previously undergone a cesarean delivery
VBAC risks
● Risk of rupture of uterus
● Risk of failed TOLAC
●risk of uterine rupture
● low risk of fetal death
Post-term pregnancy
one that has reached between 41 0/7 weeks and 41 6/7 weeks of gestation
Post-term birth risk mom
difficulties during labor, an increase in injury to the perineum, increased rate of cesarean birth, infection, postpartum hemorrhage
Post-term birth risk baby
● Stillbirth or neonatal
death
● Macrosomia: Post-term fetuses have a greater chance of developing complications related to larger body size (macrosomia)
● Fetal dysmaturity: Also called post-maturity syndrome, this refers to a fetus whose growth in the uterus after the due date has been restricted
● Oligohydramnios-single deep vertical pocket of amniotic fluid of 2 cm or less
● Fetal macrosomia
● Meconium-stained fluid
● Decreased placental reserve
Meconium-Stained Fluid and Birth
Meconium is the earliest stool of a mammalian infant, compression can cause release of meconium and be dangerous
Meconium-Stained Fluid and Birth risk
Aspiration of meconium results in respiratory distress that in severe cases can be life-threatening
Risks Associated With Multiple-Gestation Labor and Delivery
● Preterm labor
● Labor dystocia
● Antepartum hemorrhage
● Stillbirth
Stillbirth, or intrauterine fetal demise (IUFD),
fetal death after 20 weeks’ gestation
Stillbirth, or intrauterine fetal demise (IUFD) risk factors
● 1/2 are unknown ●younger than 15 older than 45 ●lower socioeconomic mothers ●maternal medical issues ●drug and alcohol ●post term pregnancy ●extreme prematurity ●infections
Intraamniotic Infection/Chorioamnionitis
infection with resultant inflammation of any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua
Intraamniotic Infection risk factors
● Migration of cervicovaginal flora through the cervical canal
● Prolonged rupture of membranes.
● Obstetric risk factors for intraamniotic infection at term have been delineated, including low parity, multiple digital examinations, use of internal uterine and fetal monitors, meconium-stained amniotic fluid, and the presence of certain genital tract pathogens
Obstetrical emergencies
urgent clinical situations that place either the maternal or fetal status at risk for increased morbidity and mortality.
Tools for obstetrical emergencies
● Availability of appropriate emergency supplies in a resuscitation cart (crash cart) or kit
● Development and implementation of a rapid response team
● Development and implementation of protocols that include clinical triggers
● Use of standardized communication tools for huddles and briefs such as SBAR (situation, background, assessment, recommendation)
● Implementation of emergency drills and simulations
Intrapartum Care Communication
assuming the best motives of others, recognizing that we all make assumptions that reflect our own worldviews, seeking first to understand others’ views and then to be understood, and avoiding stereotyping.
Shoulder dystocia
unpredictable and unpreventable obstetric emergency that places the laboring mother and neonate at risk of injury and complications
Risk Factors Associated With Shoulder Dystocia
● Fetal macrosomia (weight greater than 4,500 grams)
● Maternal diabetes
● History of shoulder dystocia
● Prolonged second stage
● Excessive weight gain
Shoulder Dystocia risks mom
severe perineal lacerations, including fourth-degree lacerations, maternal symphyseal separation and peripheral neuropathy, sphincter injuries, infection, bladder injury, or postpartum hemorrhage
Shoulder Dystocia risks baby
● Delay in delivery of the shoulders results in compression of the fetal neck by the maternal
pelvis
● Most shoulder dystocia cases are alleviated without injury to the fetus.
Prolapse of the umbilical cord
occurs when the cord lies below the presenting part of the fetus
Prolapse of the umbilical cord risks baby
● Total or partial occlusion of the cord-hypoxia
● Malpresentation of the fetus (such as breech), fetal anomalies, intrauterine growth restriction and small for gestational age (IUGR/SGA), unengaged presenting part
Prolapse of the umbilical cord risk factors
● Artifical rupture of membranes
● Polyhydramnios, multiple gestation, spontaneous ROM, preterm ROM, and grand multiparity
Vasa previa
fetal vessels unsupported by placenta or umbilical cord traverses the membranes over the cervix.
Risk Factors for Vasa Previa
● Low-lying placenta or a placenta previa
● Pregnancies in which the placenta has accessory lobes
● Multiple gestation
● Pregnancies resulting from in vitro fertilization
Risks Associated With Vasa Previa
● Fetal asphyxia from cord compression
● Fetal death from exsanguination
Rupture of the Uterus
partial or complete tear in the uterine muscle.
Risks Associated With Rupture of the Uterus
●woman and fetus include hypovolemic shock, infection, hypoxemia, acidosis, neurological damage, and possible death
● Maternal complications are primarily due to hypovolemia as a result of hemorrhage.
● Complications to the fetus may be due to uteroplacental insufficiency, placental abruption, cord compression, asphyxia, and/or hypovolemia.
hypovolemia
a decrease in the volume of blood in your body, which can be due to blood loss or loss of body fluids.
Rupture of the Uterus s/s
● Severe tearing sensation, burning or stabbing pain, and contractions
● Uterine tachysystole and/or hypertonus and vaginal bleeding
●mom-signs and symptoms of hypovolemic shock
●baby- response is related to hemorrhage and placental separation
● Ascending station of the fetal presenting part
Anaphylactic syndrome (amniotic fluid embolism)
It is hypothesized that an embolism forms when the amniotic fluid that contains fetal cells, lanugo, and vernix enters the maternal vascular system. In some patients, this can trigger an anaphylactic reaction that results in cardiorespiratory collapse.
mortality rate 61-86% and most who survive have brain damage
Risk Factors Associated With Anaphylactoid Syndrome
● Advanced maternal age 35 years or older
● Use of oxytocin for medical induction of labor
● Cesarean delivery
● Placental abnormalities (e.g., previa, abruption)
● Uterine rupture
● Assisted operative vaginal delivery (vacuum, forceps)
● Eclampsia
● Polyhydramnios
● Cervical laceration
Risks Associated With Anaphylactoid Syndrome
● Adult respiratory distress syndrome
● Heart failure
● DIC
● Multisystem organ failure
Disseminated intravascular coagulation (DIC)
a condition that prevents your body from controlling blood clotting and bleeding. Initially, blood clots form in many areas of your body.
Disseminated Intravascular Coagulation
syndrome that occurs when the body is breaking down blood clots faster than it can form a clot. This quickly depletes the body of clotting factors, leading to hemorrhage, and can rapidly lead to maternal death.
