Chapter 21 Nursing Management of Labor and Birth at Risk Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors for Dystocia • Epidural analgesia/excessive analgesia • Multiple gestation • Hydramnios • Maternal exhaustion • Ineffective maternal pushing technique • Occiput posterior position Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors for Dystocia (cont’d.) • Longer first stage of labor • Nulliparity, short maternal stature • Fetal birth weight over 8.8 lb. • Shoulder dystocia • Abnormal fetal presentation or position • Fetal anomalies Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors for Dystocia (cont’d.) • Maternal age over 35 years • High caffeine intake • Overweight • Gestational age over 41 weeks • Chorioamnionitis • Ineffective uterine contractions • High fetal station at complete cervical dilation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Causes of Dystocia • Problems with powers – Hypertonic uterine dysfunction – Hypotonic uterine dysfunction – Protracted disorders – Arrest disorders – Precipitate labor Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Causes of Dystocia • Problems with the passageway – Obstructions in maternal birth canal • Problems with psyche – Psychological distress Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Causes of Dystocia • Problems with passenger – Occiput posterior position – Breech presentation – Multifetal pregnancy – Shoulder dystocia – Macrosomia and CPD – Structural abnormalities (see Table 21.1) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Preterm Labor: Nursing Assessment • Risk factors (see Box 21.2) • Subtle signs • Contraction pattern • Laboratory and diagnostic testing: CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length via transvaginal ultrasound, home uterine activity monitoring Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Postterm Labor •Pregnancy continuing past end of 42 weeks’ gestation •Unknown etiology •Maternal risks •Fetal risks Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Postterm Pregnancy: Assessment and Management • Nursing Assessment: estimated date of birth; daily fetal movement counts, nonstress tests twice weekly, amniotic fluid analysis, weekly cervical examinations, client understanding, anxiety, and coping ability • Nursing Management: fetal surveillance; decision for labor induction; support; education, intrapartal care Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Placental Abruption • Obstetric emergency involving premature separation • Management dependent on gestational age, extent of hemorrhage, and maternal–fetal oxygenation perfusion • Prompt delivery of fetus • Cesarean birth if fetus still alive • Vaginal birth if fetal demise Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uterine Rupture • Obstetric emergency • Nursing Assessment – Risk factors – Onset of sudden fetal distress • Nursing Management – Preparation for urgent cesarean birth – Continuous maternal and fetal monitoring Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Labor Induction and Augmentation • Induction • Augmentation • Indications: prolonged gestation, prolonged premature rupture of the membranes, gestational hypertension, cardiac disease, renal disease, chorioamnionitis, dystocia, intrauterine fetal demise and diabetes Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Labor Induction: Therapeutic Management • Cervical ripening • Pharmacologic agents (see Table 21.2) • Bishop’s score • Herbal agents • Castor oil, hot baths, enemas • Sexual intercourse • Breast stimulation • Mechanical methods and surgical methods Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Labor Induction and Augmentation: Assessment and Management • Nursing Assessment – Relative indications; gestational age determination – Fetal status; maternal status; Bishop’s score • Nursing Management – Explanations (see Teaching Guidelines 21.2) – Oxytocin administration – Pain relief and support Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Forceps- or Vacuum-Assisted Birth • Uses • 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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cesarean Birth • Classic or low transverse incision (see Figure 21.8) • Major surgical procedure with accompanying risks • Nursing Assessment: history and physical examination for maternal and fetal indications • Nursing Management – Preoperative care – Postoperative care Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? Psychological stress in the woman can contribute to dystocia. a. True b. False Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer a. True Emotions such as fear, anxiety, helplessness, being alone, and weariness can lead to psychological stress, indirectly causing dystocia. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? An amnioinfusion is appropriate for a pregnant woman experiencing a prolonged second stage of labor. a. True b. False Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? Oxytocin is an important agent used to ripen the cervix for labor induction. a. True b. False Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. False Oxytocin is used to induce or augment labor once the cervix is ripe. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following assessment findings would lead the nurse to suspect an amniotic fluid embolism? a. Respiratory distress b. Hypertension c. Acute abdominal pain d. Sudden fetal distress Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer a. Respiratory distress 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
