High Risk Labor and Births
Chapter 21
Mary L. Dunlap MSN
Fall 2015
Labor and Birth at Risk
Dysfunctional Labor
• Dystocia- abnormal or difficult labor
• Leading indicator for primary cesarean
sections in the USA
• Early identification and prompt
interventions help to minimize risk to
mother and fetus
Dystocia Factors
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Maternal positioning
Powers
Passenger
Passageway
Maternal stress (psyche)
Table 21.1 pg 708-714
Maternal positioning
• Can interfere with the decent of the
fetus
• Maternal built
• Uterine abnormalities/congenital
malformations
Uterine Contractions
Hypertonic
• Uterus never fully relaxes between
contractions
• Strong, painful, ineffective contractions
• Contributing factor- maternal anxiety
Management
• Rest, hydration, sedation
Uterine Contractions
Hypotonic
• Decrease in frequency and intensity
Management
• Ambulation
• Position change
• Augmentation
Uterine Contractions
Precipitous Labor and Birth
• Rapid intense contractions
• Fetus delivered rapidly (less than 3 hrs.)
Management
• Monitor progression of labor
• Reassure and support patient
• Breathing to avoid pushing and prevent
tearing
Passenger
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•
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Persistent occiput posterior position
Breech presentation
Shoulder dystocia
Multiple gestation
Macrosomia
Passageway
• Contraction of one or more of the three
planes of the maternal pelvis: inlet,
midpelvis, and outlet
• Obstruction in the birth canal: placenta
Previa, uterine fibroids, full bladder and
cervical swelling
Maternal Psyche
Emotions
• Fear, Anxiety, Helplessness,
Exhaustion and Feeling alone cause
psychological stress
Management
• Provide physical and emotional support
• Comfort measures
• Pain management
Preterm Labor and Birth
Preterm labor and birth
• Preterm labor: cervical changes and
uterine contractions occurring between
20 and 37 weeks of pregnancy
• Preterm birth: any birth that occurs
before the completion of 37 weeks of
pregnancy
Preterm Labor and Birth
Risk Factors
• Infections
• Low Socioeconomic status
• Smoking
• Little or no prenatal care
• Domestic violence
• Box 21.2 pg.722
Preterm Labor and Birth
Predicting preterm labor and birth
• Fetal Fibronectin
• Salivary Estriol
• Transvaginal U.S.
• Home Monitoring
Preterm Labor and Birth
Uterine contractions
• Pattern more frequent than every 10
minutes persisting for 1 hour or more
Discomfort
• Dull, intermittent low back pain
• Menstrual like cramps
Preterm Labor and Birth
• Suprapubic pain or pressure
• Pelvic pressure or heaviness
• Urinary frequency
Vaginal discharge
• Change in discharge
• Rupture of amniotic membranes
Preterm Labor and Birth
Prevention
• Educate woman about early symptoms
of preterm labor
• Any symptoms of uterine contractions or
cramping between 20 and 37 weeks of
gestation that do not go away are not
normal discomforts of pregnancy require
contacting primary health care provider
Preterm Labor and Birth
Lifestyle modifications
• Activities resulting in preterm labor
Sexual activity
Carrying heavy loads
Standing more than 50% of the time
Heavy housework or climbing stairs
Hard physical work
Being unable to stop and rest when tired
Teaching Guidelines 21.1 pg. 724
Preterm Labor Management
• Bed rest
Commonly used for prevention of
preterm birth
No evidence to support effectiveness in
reducing preterm birth rates
• Tocolytics- suppression of uterine
activity
• Glucocorticoid to help accelerate fetal
lung maturity
Preterm Labor and Birth
Management of inevitable preterm birth
• 4cm dilation inevitable preterm birth
• Births in tertiary centers better neonatal
and maternal outcomes
• Women at risk improved outcome at
tertiary center
• Administer Glucocorticoids before
transfer
Prolonged Pregnancy
• Continues beyond 42 weeks
gestation
• Risk for fetal/neonatal problems
• Increase risk for cesarean birth due to
utero-placental insufficiencies
Post Term Labor and Birth
Maternal risks related to Fetal
Macrosomia
• Dystocia of labor
• Infection
• Birth trauma
• Post partum hemorrhage
Post Term Labor and Birth
Fetal Risks
• Asphyxia
• Meconium aspiration
• Hypoglycemia
• Respiratory distress
• Macrosomia- Brachial plexus injuries
• 12310
Post Term Labor and Birth
Management
• Induction of labor
• Monitor fetus for signs of
uteroplacental insufficiencies
Induction/Augmentation of Labor
• The stimulation of uterine contractions
by medical and surgical means to
produce delivery before the onset of
spontaneous labor.
• Augmentation enhances ineffective
contractions after labor has begun
Induction/Augmentation of Labor
Considerations for induction
• Post term
• Prolonged rupture of membranes
• Gestational hypertension
• Preeclampsia
• Diabetes
• Fetal demise
Induction/Augmentation of Labor
Risks
• Cesarean delivery
• Instrumented assisted delivery
• Epidural analgesia
• Fetal stress and admission to
neonatal intensive care unit
Induction Contraindications
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Complete Previa
Abruptio placenta
Transverse lie
Prolapsed umbilical cord
Previous Myomectomy
Herpes
Previous C/Sec
Induction/Augmentation of Labor
Bishop
Score
0
1
2
Dilatation
0
1-2
3-4
0-30%
40-50%
60-70%
80-100%
-3
-2
-1
+1 +2
Firm
Med
Soft
Posterior
Mid
Anterior
Effacement
Station
Cervical
consistency
Cervix
position
3
5 or more
Cervical Ripening Methods
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Nonpharmacologic
Mechanical
Surgical
Pharmacologic
Nonpharmacologic Methods
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Herbal agents
Castor oil
Enemas
Sexual intercourse
Breast stimulation
Mechanical Method
• Application of Local pressure to the
cervix stimulating the release of
prostaglandins to ripen the cervix
• Foley catheter inserted into Endocervical
canal to ripen & dilate cervix
• Hygroscopic dilators absorb
Endocervical & local tissue fluids; as
they enlarge they create mechanical
pressure (Laminaria)
Surgical Methods
• Stripping of membranes- place a finger
through the cervix and move it in a
circular direction causing the
membranes to detach
• Amniotomy with an Amniohook fetal
head now applies pressure to the cervix
stimulating increase in prostaglandins
Pharmacological
• Prostaglandins
• Oxytocin
• Drug Guide 21.2 pg.729
Oxytocin (Pitocin)
• Hormone produced by posterior
pituitary gland
• Stimulates uterine contractions
• Used to induce labor or to augment a
labor progressing slowly because of
inadequate uterine contractions
Oxytocin (Pitocin)
• Oxytocin is always administered by
infusion pump piggybacked into the
main line at the closest port to the
insertion site
• Start induction at 1-2 mU/min
• Increase rate q 30-60 min by 1-2mU
until a contraction pattern of q 2-3 min
lasting for 40 to 60 sec.
Oxytocin (Pitocin)
• Continuous fetal monitor to evaluate
contraction pattern and FHR
• Prior to starting induction verify term
pregnancy and vertex position
• If Hyperstimulation occurs turn
Oxytocin infusion off to let the uterus
rest and notify Provider
Premature Rupture of Membranes
Rupture of amniotic sac and leakage
of amniotic fluid beginning at least 1
hour before onset of labor at any
gestational age
Preterm Premature Rupture of
Membranes (PPROM)
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Rupture before 37 weeks gestation
Occurs in up to 25% of preterm labors
Often preceded by infection
Etiology unknown
Diagnosed after woman complains of
sudden gush or slow leak of vaginal
fluid
Birth Related Interventions
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Amnioinfusion
Forceps/Vacuum assisted delivery
Episiotomy
Cesarean section
VBAC
Amnioinfusion
• Warm sterile NS or RL IV solution is
infused into the uterus through an
intrauterine pressure catheter to
increase the amniotic fluid volume
• Cushion the umbilical cord
• To help thin meconium
Amnioinfusion
• Contraindications: vaginal bleeding of
unknown origin, umbilical cord prolapse,
amnionitis, uterine hypertonicity and
sever fetal distress
• Follow hospital policy for infusion
• Complications: abruption, cord prolapse,
fetal hypothermia
Forceps-Vacuum Assisted Birth
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Prolonged second stage
Fetal distress
Abnormal presentations
Arrest of rotation
Delivery of head in a breech
presentation
Forceps
Birth Related Interventions
Vacuum-assisted
• Vacuum applied to fetal head, negative
pressure to assist birth of head
–Prerequisites
• Vertex presentation
• Ruptured membranes
• Absence of CPD
Episiotomy
• Incision made in the perineum to enlarge
the vaginal outlet
• Locations- midline, R or L Mediolateral
• Alternative measures- warm compresses,
massage with oil have been successful in
stretching perineal area
Cesarean Birth
• The delivery of the fetus through an
incision in the abdomen and uterus
• Classical
• Low Transverse
• USA 1 in 3 births
Cesarean Birth indications
• Recognition of fetal distress due to
Electronic fetal monitoring
• Preserve life of mother and fetus
• Failed labor
• Failed VBAC
Cesarean Birth
Complications and Risks
• Anesthesia
• Surgical complications
• Impaired bonding
• Post partum complications
Cesarean Birth
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Preoperative care
Intraoperative care
Immediate postoperative care
Postpartum care
Cesarean Birth
• Cesarean Birth
Vaginal delivery after a Cesarean
(VBAC)
• A woman who has had a previous
cesarean and gives birth vaginally after
at least one previous cesarean birth.
• Controversial choice
• Risk for uterine rupture, hemorrhage
and fetal mortality
VBAC
Contraindications
• Prior classic uterine incision
• Uterine scar other than a low transverse
• Prior transfundal uterine surgery
• Inadequate staff or facility
• Use of cervical ripening agents
VBAC
• Special areas of focus: consent,
documentation, surveillance, and
readiness for emergency
• Nursing care is focused FHR tracing to
identify nonreassuring pattern and
instituting measures for emergency
delivery
Obstetric Emergencies
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Umbilical cord prolapse
Placenta Previa
Placental abruption
Uterine rupture
Shoulder Dystocia
Fetal Demise
Cord Prolapse
Lies below presenting part of fetus
Contributing factors
• Long cord (longer than 100 cm)
• Malpresentation (breech)
• Transverse lie
• Unengaged presenting part
• Hydramnios
Cord Prolapse
Cord Prolapse
Management
• Hold the presenting part off the umbilical
cord until delivery
• Change patients position to relieve cord
pressure
• Monitor fetal heart rate
• Emotional support
• Pre-per for c/sec
Cord Prolapse
Cord Prolapse
Placenta Previa
• Placental implantation in the lower
uterine segment
• Position can create a barrier for
vaginal delivery of the fetus
Placental Abruption
• Premature separation of placenta
Management
• Based on gestational age, extent of
hemorrhage and maternal-fetal oxygenation
perfusion
• Maintain maternal cardiovascular status
• Prompt delivery
• Cesarean birth if fetus still alive; vaginal birth
if fetal demise
Uterine Rupture
• Uterine tearing at the site of a
previous scar.
Causes
• Uterine trauma: accidents, surgery
• Congenital uterine anomaly
• Intense uterine contractions
Uterine Rupture
Causes
• Labor stimulation
• Over distended uterus
• Malpresentation: external or internal
version
• Difficult forceps-assisted birth
• More often in Multigravidas
Uterine Rupture
• Management
• Pre pare mother for Stat emergency
C/sec
• Administer IV fluid & blood to combat
hemorrhage
• O2 to help with fetal compromised
• Mother will be anxious stay calm
Shoulder Dystocia
• Head is born, anterior shoulder
cannot pass under pubic arch
• Delivery can cause newborn birth
injuries
• Maternal risk: excessive blood loss,
lacerations, extension of episiotomy,
or Endometritis
Shoulder Dystocia
Management
• McRoberts maneuver
• Suprapubic pressure
Shoulder Dystocia
• Shoulder Dystocia simulation
• Shoulder Dystocia delivery