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)