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C h a p t e r
Labor and Birth at Risk
DEITRA LEONARD LOWDERMILK
LEARNING OBJECTIVES
•
•
•
•
•
•
Differentiate between preterm birth and low
birth weight.
Identify the risk factors for preterm labor.
Evaluate current interventions to prevent
preterm birth.
Discuss the use of tocolytics and antenatal glucocorticoids in preterm labor and birth.
Examine the effects of prescribed bed rest on
pregnant women and their families.
Summarize the nursing care management of
women with preterm premature rupture of
membranes.
•
•
•
Demonstrate knowledge of nursing management for a trial of labor, the induction and augmentation of labor, forceps- and vacuumassisted birth, cesarean birth, and vaginal birth
after a cesarean birth.
Explain the care of a woman with postterm
pregnancy.
Discuss obstetric emergencies and their appropriate management.
KEY TERMS AND DEFINITIONS
amniotic fluid embolism (AFE) Embolism resulting
from amniotic fluid entering the maternal bloodstream during labor and birth after rupture of
membranes; often fatal to the woman if it is a pulmonary embolism
antenatal glucocorticoids Medications administered to the mother for the purpose of accelerating fetal lung maturity when there is increased risk
for preterm birth between 24 and 34 weeks of
gestation
augmentation of labor Stimulation of ineffective
uterine contractions after labor has started spontaneously but is not progressing satisfactorily
Bishop score Rating system to evaluate inducibility (ripeness) of the cervix; a higher score increases the likelihood of a successful induction of
labor
cephalopelvic disproportion (CPD) Condition in
which the infant’s head is of such a shape, size,
or position that it cannot pass through the
mother’s pelvis or the maternal pelvis is too small,
abnormally shaped, or deformed to allow the passage of a fetus of average size
cesarean birth Birth of a fetus by an incision
through the abdominal wall and uterus
chorioamnionitis Inflammatory reaction in fetal
membranes to bacteria or viruses in the amniotic
fluid, which then become infiltrated with polymorphonuclear leukocytes
dysfunctional labor Abnormal uterine contractions that prevent normal progress of cervical dilation, effacement, or descent
dystocia Prolonged, painful, or otherwise difficult
labor caused by various conditions associated with
the five factors affecting labor (powers, passage,
passenger, maternal position, and maternal
emotions)
external cephalic version (ECV) Turning of the fetus to a vertex presentation by external exertion of
pressure on the fetus through the maternal
abdomen
forceps-assisted birth Vaginal birth in which forceps (i.e., curved-bladed instruments) are used to
assist in the birth of the fetal head
hypertonic uterine dysfunction Uncoordinated,
painful, frequent uterine contractions that do not
cause cervical dilation and effacement; primary
dysfunctional labor
hypotonic uterine dysfunction Weak, ineffective
uterine contractions usually occurring in the active
phase of labor; often related to cephalopelvic disproportion or malposition of the fetus; secondary
uterine inertia
oxytocin Hormone produced by the posterior pituitary gland that stimulates uterine contractions and
the release of milk in the mammary glands (letdown reflex); synthetic oxytocin is a medication
that mimics the uterine stimulating action of
oxytocin
postterm pregnancy Pregnancy prolonged past 42
weeks of gestation
precipitous labor Rapid or sudden labor lasting less
than 3 hours from the onset of uterine contractions to complete birth of the fetus
Continued
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KEY TERMS AND DEFINITIONS—cont’d
premature rupture of membranes (PROM) Rupture of the amniotic sac and leakage of amniotic
fluid beginning at least 1 hour before the onset of
labor at any gestational age
preterm birth Birth occurring before the completion
of 37 weeks of gestation
preterm labor Cervical changes and uterine contractions occurring between 20 weeks and 37 weeks
of pregnancy
preterm premature rupture of membranes
(PPROM) PROM that occurs before 37 weeks of
gestation
prolapse of the umbilical cord Protrusion of the
umbilical cord in advance of the presenting part
shoulder dystocia Condition in which the head is
born but the anterior shoulder cannot pass under
the pubic arch
therapeutic rest Administration of analgesics and
implementation of comfort or relaxation measures
to decrease pain and induce rest for management
of hypertonic uterine dysfunction
tocolytics Medications used to suppress uterine activity and relax the uterus in cases of hyperstimulation or preterm labor
trial of labor (TOL) Period of observation to determine whether a laboring woman is likely to be successful in progressing to a vaginal birth
vacuum-assisted birth Birth involving attachment
of a vacuum cap to the fetal head (occiput) and application of negative pressure to assist in birth of
the fetus
vaginal birth after cesarean (VBAC) Giving birth
vaginally after having had a previous cesarean birth
ELECTRONIC RESOURCES
Additional information related to the content in Chapter 24 can be found on
The companion website at
http://evolve.elsevier.com/Lowdermilk/Maternity/
• NCLEX Review Questions
• Case Study—Preterm Labor
• Case Study—Postdate Pregnancy
• WebLinks
W
hen complications arise during labor and birth, risk of perinatal morbidity and mortality increases.
Some complications are anticipated, especially if the mother is identified as high risk during the antepartum period; others are unexpected or unforeseen. The woman, her family, and the obstetric team can
feel devastated when things go wrong. Nurses must recognize these feelings if they are to provide effective support.
It is crucial for nurses to understand the normal birth process
to prevent and detect deviations from normal labor and birth
and to implement nursing measures when complications
arise. Optimal care of the laboring woman, fetus, and family experiencing complications is possible only when the
nurse and other members of the obstetric team use their
knowledge and skills in a concerted effort to provide
care. This chapter focuses on the problems of preterm labor
and birth, dystocia, and postterm pregnancy and obstetric
emergencies.
PRETERM LABOR AND BIRTH
Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy.
Preterm birth is any birth that occurs before the completion
of 37 weeks of pregnancy (American College of Obstetricians
and Gynecologists [ACOG] & American Academy of Pediatrics [AAP], 2002). Preterm labor and birth are the most
or on the interactive companion CD
• NCLEX Review Questions
• Case Study—Preterm Labor
• Case Study—Postdate Pregnancy
• Plan of Care—Dysfunctional Labor
• Plan of Care—Preterm Labor
serious complications of pregnancy because they lead to
about 90% of all neonatal deaths, with more than 75% of
these deaths occurring in infants born at fewer than 32 weeks
of gestation. Preterm birth is second only to congenital anomalies as a cause of infant mortality. In 2003 the preterm birth
rate for all races in the United States was 12.3% (Hamilton,
Martin, Sutton, & Centers for Disease Control and Prevention [CDC], National Center for Health Statistics, 2004).
Preterm Birth versus
Low Birth Weight
Although they have distinctly different meanings, the terms
preterm birth or prematurity and low birth weight are often used
interchangeably (Moos, 2004). Preterm birth describes length
of gestation (i.e., less than 37 weeks regardless of the weight
of the infant), whereas low birth weight describes only weight
at the time of birth (i.e., 2500 g or less). Low birth weight is
far easier to measure than preterm birth, and therefore in
many settings and publications, low birth weight has been
used as a substitute term for preterm birth. Preterm birth,
however, is a more dangerous health condition for an infant
because a decreased length of time in the uterus correlates
with immaturity of body systems. Low-birth-weight babies
can be, but are not necessarily, preterm; low birth weight can
be caused by conditions other than preterm birth, such
as intrauterine growth restriction (IUGR), a condition of
inadequate fetal growth not necessarily correlated with initiation of labor.
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The incidence of preterm birth in the United States is increasing and varies according to race; the 2002 rate for
African-Americans (17.7%) was considerably higher than that
for American Indians (13.1%), Hispanics (11.6%), Caucasians (11%), and Asians and Pacific Islanders (10.4%)
(Martin et al., 2003). The increase in rates is attributed largely
to the increase in multiple births. Sociodemographics may
play a part in the race-based differences in preterm birth.
Preterm birth rates are higher among socially disadvantaged
populations, including minorities, women with low levels of
education, and women who receive late or no prenatal care
(Martin et al., 2003; Maupin et al., 2004). The preterm birth
rate is higher among women younger than 15 years of age
or older than 45 years (Martin et al., 2003). Multifetal pregnancy from in vitro fertilization also is associated with an
increase in preterm births (Moore, 2003).
Predicting Preterm Labor
and Birth
The known risk factors for preterm birth are shown in Box
24-1. The risk factors most commonly associated with preterm labor and birth are a history of preterm birth, race (e.g.,
African-American), and multiple gestation (Martin et al.,
2003). Using these risk factors, researchers have tried to determine which women might go into labor prematurely. No
risk scoring system has resulted in lowering the preterm birth
rate in the United States, however, because at least 50% of
all women who ultimately give birth prematurely have no
identifiable risk factors (Martin et al., 2003). The March of
Dimes has started a 5-year, $75 million campaign to address
the problem of prematurity. The Association of Women’s
Health, Obstetric and Neonatal Nurses (AWHONN) is a
partner in this project. AWHONN is helping to increase
screening for known risk factors and to teach women the
signs and symptoms of preterm labor (Nelson, 2004). It is
important that all women be educated about prematurity not
only in early pregnancy but also in the preconception period (Freda & Patterson, 2001; Massett et al., 2003).
Biochemical markers
The two most common biochemical markers used in an
effort to predict who might experience preterm labor are fetal fibronectin and salivary estriol (Goldenberg et al., 2003).
Fetal fibronectins are glycoproteins found in plasma and
produced during fetal life. They appear in the cervical canal
early in pregnancy and then again in late pregnancy. Their
appearance between 24 and 34 weeks of gestation predicts
labor (Bernhardt & Dorman, 2004; Ramsey & Andrews,
2003). The negative predictive value of fetal fibronectin is
high (up to 94%). The positive predictive value is lower
(46%) (Iams & Creasy, 2004). This means that it may be possible to predict who will not go into preterm labor, but not
who will (Bernhardt & Dorman, 2004). The test is done during a vaginal examination.
Salivary estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels
of salivary estriol have been shown to increase before
24
Labor and Birth at Risk
771
BOX 24-1
Risk Factors for Preterm Labor
DEMOGRAPHIC RISKS
•
•
•
•
•
Nonwhite race
Age (15 years, 45)
Low socioeconomic status
Unmarried
Less than high school education
BIOPHYSICAL RISKS
•
•
•
•
•
•
•
•
•
•
Previous preterm labor or birth
Second-trimester abortion (more than two spontaneous or therapeutic); stillbirths
Grand multiparity; short interval between pregnancies,
1 year since last birth); fmily history of preterm labor
and birth
Progesterone deficiency
Uterine anomalies or fibroids; uterine irritability
Cervical incompetence, trauma, shortened length
Exposure to DES or other toxic substances
Medical diseases (e.g., diabetes, hypertension, anemia)
Small stature (119 cm in height; 45.5 kg or underweight for height)
Current pregnancy risks:
–Multifetal pregnancy
–Hydramnios
–Bleeding
–Placental problems (e.g., placenta previa, abruptio
placentae)
–Infections (e.g., pyelonephritis, recurrent urinary tract
infections, asymptomatic bacteriuria, bacterial vaginosis, chorioamnionitis)
–Gestational hypertension
–Premature rupture of the membranes
–Fetal anomalies
–Inadequate plasma volume expansion; anemia
BEHAVIORAL-PSYCHOSOCIAL RISKS
•
•
•
•
•
•
•
Poor nutrition; weight loss or low weight gain
Smoking (10 cigarettes a day)
Substance abuse (e.g., alcohol; illicit drugs, especially
cocaine)
Inadequate prenatal care
Commutes of more than 11⁄ 2 hours each way
Excessive physical activity (heavy physical work, prolonged standing, heavy lifting, care of young child)
Excessive lifestyle stressors
Sources: Cunningham et al., (2005). Williams’ obstetrics (22nd ed.). New
York: McGraw-Hill; Gilbert, E., & Harmon, J. (2003). Manual of high risk pregnancy and delivery (3rd ed.). St. Louis: Mosby; Iams, J. (2002). Preterm birth.
In S. Gabbe, J. Niebyl, & J. Simpson (Eds.). Obstetrics: Normal and problem pregnancies (4th ed.). New York: Churchill Livingstone; Martin, J. et al.
(2003). Births: Final data for 2002. National Vital Statistics Report, 52(10),
1-113; & Moore, M. (2003). Preterm labor and birth: What have we learned
in the past two decades? Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 32(5), 638-649.
preterm birth. Specimens of salivary estriol are collected by
the woman in the home. The testing is done every 2 weeks
for about 10 weeks. This marker also has a high negative predictive value (98%) and a lower positive predictive value (7%
to 25%) (Bernhardt & Dorman, 2004).
Evolve/CD: Case Study—Preterm Labor
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More research is needed before it will be known if these
markers offer valuable assistance that is cost effective in the
risk assessment for preterm labor.
Endocervical length
Another possible predictor of imminent preterm labor
is endocervical length. Some studies have suggested that
a shortened cervix precedes preterm labor and can be
determined by ultrasound measurement (Bernhardt &
Dorman, 2004; Fuchs, Henrich, Osthues, & Dudenhausen,
2004). Women whose cervical length is 35 mm at 24 to
28 weeks of gestation are more likely to have a preterm
birth than women whose cervical length exceeds 40 mm.
When a woman has a short cervix combined with a positive fetal fibronectin result, her risk for spontaneous
preterm birth is substantially higher than that for women
positive for only one marker or none at all (Iams & Creasy,
2004).
Causes of preterm labor and birth
The cause of preterm labor is unknown and is assumed
to be multifactorial. Infection is thought to be a major eti-
Critical Thinking Exercise
Preterm Labor
You are assigned to Yolanda, who is experiencing preterm
labor at 28 weeks of gestation. She has a 2-year-old son
at home. This is her third admission for preterm labor during this pregnancy. Her primary health care provider has
told her she must remain hospitalized on bed rest until
she reaches 37 weeks of gestation or until birth of the
baby, whichever comes first. She tearfully asks you why
she can’t be at home on bed rest, who will help care for
her son, and how she will manage to keep from going
crazy staying in bed that long. How will you respond to
her concerns?
1 Is there sufficient evidence to draw conclusions about
the benefits of bed rest to prevent preterm birth?
2 What assumptions can be made about the following
issues?
a. The impact her history might have on the medical
and nursing care she receives during this pregnancy
b. The pros and cons of home management versus
hospital management for the prevention of preterm
birth for this woman
c. Ways to reduce the frustration and boredom that
are experienced during restriction to bed rest for
several weeks
d. Resources available to assist with care of her
2-year-old son
3 What implications and priorities for nursing care can
be drawn at this time?
4 Does the evidence objectively support your conclusion?
5 Are there alternative perspectives to your conclusion?
ologic factor in some preterm labors, but trials of antibiotic
therapy for all women at risk have not resulted in statistically
significant reductions in preterm births (Iams & Creasy,
2004). When cervical, bacterial, or urinary tract infections
are present, the risk of preterm birth is increased; therefore
early, continuous, and comprehensive prenatal care, which
can detect and treat infection, is essential in dealing with this
aspect of preterm birth prevention.
Not all preterm births can or even should be prevented.
About 25% of all preterm births are iatrogenic, that is, babies are intentionally delivered prematurely because of pregnancy complications that put the life or health of the fetus
or mother in danger, not because of preterm labor. Another
25% of all preterm births are preceded by spontaneous rupture of the membranes (preterm premature rupture of the
membranes) followed by labor. These preterm births are not
known to be preventable. About 50% of preterm births,
therefore, are possibly amenable to prevention efforts and
are considered idiopathic preterm births (Iams & Creasy,
2004).
Sociodemographic factors such as poverty, low educational level, lack of social support, smoking, little or no
prenatal care, domestic violence, and stress are thought to
contribute to the 50% of preterm births that may be preventable (Gennaro & Hennessy, 2003; Iams & Creasy, 2004).
If prenatal care programs are to be effective in reducing the
rate of preterm labor and birth, they must address these sociodemographic factors and develop strategies to attract all
women to participate, including those at high risk for
preterm labor (Maloni, 2000).
CARE MANAGEMENT
Assessment and Nursing
Diagnoses
Because all pregnant women must be considered at risk for
preterm labor (as they are for any other pregnancy complication), nursing assessment begins at the time of entry to prenatal care. The onset of preterm labor is often insidious and
can be easily mistaken for normal discomforts of pregnancy.
It is essential that nurses teach pregnant women how to detect the early symptoms of preterm labor (Box 24-2) (Freda
& Patterson, 2001; Witcher, 2002).
The nurse caring for women in a prenatal setting should
use known successful modalities for teaching the pregnant
woman about early recognition of preterm symptoms and
then reassess the woman at each prenatal visit for the symptoms of preterm labor. Pregnant women also must be taught
what to do if the symptoms of preterm labor occur. Some
women wait hours or days before contacting a health care
provider after preterm labor symptoms have begun. Women
may ignore the symptoms because of ignorance regarding
their significance or a belief that the symptoms are expected
during pregnancy. The symptoms may be attributed to other
factors such as the flu, incontinence of urine, or working too
hard. Some women will become more vigilant, waiting to see
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BOX 24-2
Signs and Symptoms of Preterm Labor
UTERINE ACTIVITY
•
•
Uterine contractions more frequent than every 10 minutes persisting for 1 hour or more
Uterine contractions may be painful or painless
DISCOMFORT
•
•
•
•
•
•
Lower abdominal cramping similar to gas pains; may
be accompanied by diarrhea
Dull, intermittent low back pain (below the waist)
Painful, menstrual-like cramps
Suprapubic pain or pressure
Pelvic pressure or heaviness
Urinary frequency
VAGINAL DISCHARGE
•
•
Change in character and amount of usual discharge:
thicker (mucoid) or thinner (watery); bloody, brown, or
colorless; increased amount; odor
Rupture of amniotic membranes
if the symptoms subside, go away, or become worse. Some
women may take action by seeking advice about what to do
from family or friends, resting more, increasing fluid intake,
taking a bath, or rubbing the back or abdomen. Persistence
of symptoms and increasing severity finally compel women
to seek health care (Weiss, Saks, & Harris, 2002). Waiting too
long to see a health care provider could result in inevitable
preterm birth without the benefit of the administration of
antenatal glucocorticoids (i.e., medication given to accelerate fetal lung maturity). In this event, the neonate is born
at higher risk for respiratory distress syndrome and intraventricular hemorrhage.
The nurse must assess the psychosocial and emotional status of women in preterm labor and the impact that treatment
(e.g., bed rest, hospitalization) can have on family dynamics. Factors influencing the impact of preterm labor treatment include stability of the support system, financial status, and availability of child support and assistance with
household maintenance. Pregnant women who have risk factors for preterm birth are often offered special care with more
frequent visits. Although there is no evidence in the literature that this enhanced care results in better outcomes, clinically it makes sense to evaluate at-risk women on a more frequent basis. Freda and Patterson (2001) suggest that the
power of nursing care, nursing support, and patient education in the care of women at high risk for preterm birth can
affect the occurrence and early detection of preterm labor.
Nursing diagnoses relevant for women at risk for preterm
birth include the following:
•
Risk for maternal excess fluid volume related to
—administration of tocolytics to suppress preterm
labor
•
•
•
•
24
Labor and Birth at Risk
773
Interrupted family processes related to
—required limitation on maternal activity associated
with preterm labor
Impaired mobility related to
—prescribed bed rest
Anticipatory grieving related to
—potential for birth of preterm infant
Risk for impaired parent-infant attachment related to
—care requirements of preterm infant
Expected Outcomes of Care
Expected outcomes include that the woman will do the following:
Learn the signs and symptoms of preterm labor and
be able to assess herself and her need for intervention
Follow teaching suggestions and call her primary
health care provider if symptoms occur
Not experience preterm symptoms, or, if she does, she
will take appropriate action
Maintain her pregnancy for at least 37 completed
weeks
Give birth to a healthy, full-term infant
•
•
•
•
•
Plan of Care and Interventions
Prevention
Prevention strategies that address risk factors associated
with preterm labor and birth are less costly in human and
financial terms than the high-tech and often lifelong care required by preterm infants and their families. Programs aimed
at health promotion and disease prevention that encourage
healthy lifestyles for the population in general and women
of childbearing age in particular should be developed to prevent preterm labor and birth (Freda, 2003; Heaman, Sprague,
& Stewart, 2001; Tiedje, 2003). One of the most important
nursing interventions aimed at preventing preterm birth is
the education of pregnant women about the early symptoms
of preterm labor, so that if symptoms occur the woman can
be referred promptly to her care provider for more intensive
care (Freda, 2003; Moore, 2003). Box 24-2 identifies the
symptoms of preterm labor, and the Guidelines/Guías box
identifies what the woman should do if the symptoms appear. Patient education regarding any symptoms of contractions or cramping between 20 and 37 weeks of gestation
should be directed toward telling the woman that these
symptoms are not normal discomforts of pregnancy, and
that contractions or cramping that do not go away should
prompt the woman to contact her primary health care
provider. Because no one can discriminate between Braxton
Hicks contractions and the contractions of early preterm labor, Freda and Patterson (2001) suggest that the term Braxton Hicks contractions be eliminated from teaching about pregnancy expectations (Fig. 24-1).
Early recognition and diagnosis
Early recognition of preterm labor is essential to successfully implement interventions such as tocolytic therapy and
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GUIDELINES/GUÍAS
What to Do if Symptoms of
Preterm Labor Occur
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Empty your bladder.
Vacíese la vejiga.
Drink two to three glasses of water or juice.
Tome dos a tres vasos de agua o jugo.
Lie down on your left side for 1 hour.
Acuéstese del lado izquierdo por una hora.
Palpate for contractions like this.
Palpe por contracciones así.
If symptoms continue, call your health care provider or
go to the hospital.
Si continúan los síntomas, llame a su proveedor de los
servicios de salud/médico o vaya al hospital.
If symptoms abate, resume light activity, but not what
you were doing when the symptoms began.
Si se alivian los síntomas, resuma sus actividades livianas, pero no haga lo que estaba haciendo cuando
empezaron los síntomas.
If symptoms return, call your health care provider or go
to the hospital.
Si se presentan de nuevo los síntomas, llame a su
proveedor de los servicios de salud/médico o vaya al
hospital.
If any of the following symptoms occur, call your health
care provider immediately:
Si le sucede cualquier de los siguientes síntomas, llame
inmediatamente a su proveedor de los servicios de
salud/médico:
—Uterine contractions every 10 minutes or less for
1 hour or more
—Contracciones uterinas cada diez minutos o menos
que duran por una hora o más
—Vaginal bleeding
—Hemorragia vaginal
—Odorous vaginal discharge
—Flujo vaginal con mal olor
—Fluid leaking from the vagina
—Flujo que le sale de la vagina
administration of antenatal glucocorticoids. The diagnosis of
preterm labor is based on three major diagnostic criteria:
Gestational age between 20 and 37 weeks
Uterine activity (e.g., contractions)
Progressive cervical change (e.g., effacement of 80%,
or cervical dilation of 2 cm or greater)
If the presence of fetal fibronectin is used as another diagnostic criterion, a sample of cervical mucus for testing
should be obtained before an examination for cervical
changes, because the lubricant used to examine the cervix
can reduce the accuracy of the test for fetal fibronectin.
The pregnant woman at 30 weeks with an irritable uterus
but no documented cervical change is not in preterm labor.
Misdiagnosis of preterm labor can lead to inappropriate use
•
•
•
Fig. 24-1 Nurse teaching woman signs and symptoms of
preterm labor. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa
Mesa, CA.)
of pharmacologic agents that can be dangerous to the health
of the woman, the fetus, or both (Abrahams & Katz, 2002;
ACOG/AAP, 2002).
Lifestyle modifications
Nurses caring for women with symptoms of preterm labor should question the woman about whether she has
symptoms when engaged in any of the following activities:
Sexual activity
Riding long distances in automobiles, trains, or buses
Carrying heavy loads such as laundry, groceries, or a
small child
Standing more than 50% of the time
Heavy housework
Climbing stairs
Hard physical work
Being unable to stop and rest when tired
If symptoms occur when the woman is engaged in any
of these activities, the woman should consider stopping
those activities until 37 weeks of pregnancy when preterm
birth is no longer a risk. Counseling about lifestyle modification should be individualized; only women who have
symptoms of preterm labor when they are engaged in certain activities need to alter their lifestyles. No specific rules
describe which activities are safe for pregnant women and
which are not. Each pregnant woman must understand
which lifestyle factors might be contributing to her symptoms and be taught to modify only those factors. Sexual activity, for instance, is not contraindicated during pregnancy.
If, however, symptoms of preterm labor occur after sexual
activity, then that activity may need to be curtailed until
37 weeks of gestation.
•
•
•
•
•
•
•
•
Bed rest
Bed rest is a commonly used intervention for the prevention of preterm birth. Although frequently prescribed,
bed rest is not a benign intervention, and there is no evi-
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dence in the literature to support the efficacy of this intervention in reducing preterm birth rates. It is a form of care
of unknown effectiveness (Enkin et al., 2000; Sosa,
Athalbe, Belzian, & Bergel, 2004). Maloni and colleagues
(1993) described deleterious effects of bed rest on women:
after 3 days there is decreased muscle tone, weight loss, calcium loss, and glucose intolerance. Weeks of bed rest lead
to bone demineralization, constipation, fatigue, isolation,
anxiety, and depression (Box 24-3). Symptoms often are not
resolved by 6 weeks postpartum (Maloni & Park, 2005). Bed
rest is costly for society; the estimated economic costs are
based on lost wages, household help and child care expenses,
and hospital costs (Maloni, Brezinski-Tomasi, & Johnson,
2001). Prolongation of pregnancy does not necessarily occur despite the increased costs incurred. Women on bed rest
need support and encouragement whether they are at home
or are hospitalized. Nurses can create support groups of hospitalized women on bed rest. Internet resources including
chat rooms for women on bed rest at home, as well as family and friends, can be important sources of support for the
women and reduce the sense of isolation they may feel. Interacting with other women experiencing preterm labor and
bed rest has been found to be highly therapeutic (Adler &
Zarchin, 2002; Maloni & Kutil, 2000).
Home care
Women who are at high risk for preterm birth commonly
are told that it would be best if they were at home on bed
BOX 24-3
Adverse Effects of Bed Rest
MATERNAL EFFECTS (PHYSICAL)
•
•
•
•
•
•
•
•
Weight loss
Muscle wasting, weakness
Bone demineralization and calcium loss
Decreased plasma volume and cardiac output
Increased clotting tendency; risk for thrombophlebitis
Alteration in bowel function
Sleep disturbance, fatigue
Prolonged postpartum recovery
MATERNAL EFFECTS (PSYCHOSOCIAL)
•
•
•
•
•
Loss of control associated with role reversals
Dysphoria-anxiety, depression, hostility, and anger
Guilt associated with difficulty complying with activity
restriction and inability to meet role responsibilities
Boredom, loneliness
Emotional lability (mood swings)
EFFECTS ON SUPPORT SYSTEM
•
•
•
Stress associated with role reversals, increased responsibilities, and disruption of family routines
Financial strain associated with loss of maternal income and cost of treatment
Fear and anxiety regarding the well-being of the mother
and fetus
24
Labor and Birth at Risk
775
rest for weeks or months. The home care of the woman at
risk for preterm birth is a challenge for the nurse, who must
assist the woman and her family in dealing with the many
difficulties faced by families in which one member is incapacitated. The scope of care given to women in their homes
ranges from occasional visits to monitor the maternal and
fetal condition, to daily telephone consultation and reading
of uterine monitoring strips.
Regardless of the frequency of the visits, nursing care for
the woman and family in the home demands organization
and a sense of just how this family’s life has been disrupted
by the loss of activity of this essential family member. Families, who are often anxious regarding the health status of
the mother and baby, may need help in learning how to organize time and space or to restructure family routines so
that the pregnant woman can remain a part of family activity
while still maintaining bed rest. It also is important for the
nurse to work toward assisting all the family members to
explore their feelings regarding the anxieties of preterm labor and help them to share their feelings with one another
(Maloni, Brezinski-Tomasi & Johnson, 2001). Box 24-4 and
the Patient Instructions for Self-Care Box list activities for
women on bed rest and for their children.
The woman’s environment can be modified for convenience by using tables and storage units around her bed
to keep essential items within reach (e.g., telephone, television, radio, tape or compact disc player, computer with Internet access, snacks, books, magazines, and newspapers,
items for hobbies) (Fig. 24-2). Ensuring that the bed or couch
is near a window and the bathroom is also helpful. Covering the bed with an egg crate mattress can relieve discomfort. Women often find that a daily schedule of meals, activities, and hygiene and grooming (e.g., shower, dressing in
street clothes, applying make-up) that they create reduces
boredom and helps them maintain control and normalcy.
BOX 24-4
Activities for Children of Women on Bed
Rest
•
•
•
•
•
•
•
•
•
Schedule brief play periods throughout the day.
Keep a few favorite toys in a box or basket close to the
bed or couch.
Read to the child(ren).
Put puzzles together.
Watch videos, play video games (remote control for TV
is ideal).
Play cards or board games.
Color in coloring books.
Cut out pictures from magazines and paste on cardboard.
Play bed basketball with a soft (sponge) ball or rolled
up sock and a trash can or empty laundry basket.
References: McCann, M. (2003). Days in waiting: A guide to surviving
bedrest. St. Paul, MN: deRuyter-Nelson Publications; & Tracy, A. (2001). The
pregnancy bed rest book: A survival guide for expectant mothers and their
families. New York: Berkley Publishing Group.
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PATIENT INSTRUCTIONS
FOR SELF-CARE
Suggested Activities for Women on
Bed Rest
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Set a routine for daily activities (e.g., getting dressed,
moving from the bedroom to a “day bed-rest place,”
having social time, eating meals, self-monitoring fetal
and uterine activity).
Do passive exercises as allowed.
Review childbirth education information or have a childbirth class at home, if this can be arranged.
Plan menus and make up grocery shopping lists.
Shop by phone.
Read books about high risk pregnancy or other topics.
Keep a journal of the pregnancy.
Keep a calendar of your progress.
Reorganize files, recipes, household budget.
Update address book.
Do mending, sewing.
Listen to audiotapes, watch videos or television.
Do crossword puzzles, jigsaw puzzles, etc.
Do craft projects; make something for the baby.
Put pictures in photo albums.
Call a friend, family member, or support person each
day or use email.
Treat yourself to a facial, manicure, neck massage, or
other special treat when you need a lift.
Sources: Gilbert, E., & Harmon, J. (2003). Manual of high risk pregnancy and delivery (3rd
ed.). St. Louis: Mosby; McCann, M. (2003). Days in waiting: A guide to surviving bedrest.
St. Paul, MN: deRuyter-Nelson Publications; Moondragon Birthing Services. (2005).
Moondragon’s pregnancy information: Coping with bedrest during pregnancy. Internet
document available at www.moondragon.org/pregnancy/bedrestcope.html (accessed
May 1, 2005); & Tracy, A. (2001). The pregnancy bed rest book: A survival guide for expectant mothers and their families. New York: Berkley Publishing Group.
Limiting naps, eating smaller but more frequent meals, and
performing gentle range-of-motion exercises can help to reduce some of the detrimental effects of bed rest. It is essential
that women and their families recognize that postpartum recovery will be slower as she works to regain strength and
stamina (Maloni, 2002).
Home uterine activity monitoring
Home uterine monitoring systems were developed to provide home uterine monitoring services for women diagnosed
with preterm labor. Nurses are usually an integral part of the
home uterine activity monitoring (HUAM) systems to educate and provide care to the women. The use and effectiveness of HUAM continues to be controversial. Enkin and
colleagues (2000) found HUAM a form of care unlikely to
be beneficial in preventing preterm birth. However, a comprehensive evidence-based review of clinical data suggests
that if used correctly (e.g., twice daily monitoring of uterine
activity and daily nursing care) in women at risk for preterm
birth, HUAM increases the incidence of early diagnosis of
preterm labor, prolongation of pregnancy with fewer preterm
births, and reduced neonatal morbidity when study groups
are compared with control groups of women receiving standard prenatal care in the United States (Morrison &
Fig. 24-2 Woman at home on restricted activity for
preterm labor prevention. Note how she has arranged her daytime resting area so that needed items are close at hand.
(Courtesy Amy Turner, Cary, NC.)
Chauhan, 2003). Research should be continued in this area
to determine what place HUAM has in preterm labor care.
Suppression of uterine activity
Tocolytics. Should preterm labor occur, women are
usually admitted to the hospital for assessment; fetal monitoring; cervical or vaginal cultures; assessment of cervical
status, amniotic fluid leakage, and elevated maternal temperature (an early sign of chorioamnionitis). The initiation
of tocolytic therapy might be considered at this time. Once
the pregnancy has progressed beyond 34 weeks of gestation,
the benefits of prolonging the pregnancy do not justify the
maternal risk of tocolytic therapy (Witcher, 2002). The use
of tocolytics (medications that suppress uterine activity) in
an attempt to prevent preterm birth has been the subject of
research since the late 1970s. At first, it was thought that use
of tocolytic therapy could prolong a threatened pregnancy
indefinitely; research has demonstrated only a small improvement in prolonging pregnancy to a term birth. Once
uterine contractions are suppressed, maintenance therapy
may be implemented in an attempt to continue the suppression, or tocolytic treatment can be discontinued and resumed only if uterine contractions begin again. Research
findings suggest that there appears to be no significant difference when tocolytic treatment approaches are compared
and that continued maintenance tocolytic therapy has no
more than minimal value (Berkman et al., 2003).
It is now thought that the best reason to use tocolytics
is that they afford the opportunity to begin administering
antenatal glucocorticoids to accelerate fetal lung maturity
and reduce the severity of sequelae in infants born preterm
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(Anotayanonth, Subhedar, Garner, Neilson, & Harigopal,
2004). Medications used for this purpose include ritodrine
(Yutopar), terbutaline (Brethine), magnesium sulfate, indomethacin (Indocin), and nifedipine (Procardia). Ritodrine
is the only medication approved by the U.S. Food and Drug
Administration (FDA) specifically for the purpose of cessation of uterine contractions; however, magnesium sulfate,
terbutaline, and nifedipine are most commonly used in U.S.
hospitals (Rideout, 2005). These drugs are used on an “offlabel” basis (i.e., drugs known to be effective for a specific
purpose, although not specifically developed and tested for
this purpose). Important contraindications exist to the use
of all tocolytics (Box 24-5). Because these medications have
the potential for serious adverse reactions for mother and fetus, close nursing supervision during treatment is critical
(Lehne, 2001) (Box 24-6 and Medication Guide).
Magnesium sulfate is the most commonly used tocolytic
agent, because maternal and fetal or neonatal adverse reactions are less common than with other tocolytic agents, especially the beta-adrenergic agonists. Although its exact
mechanism of action on uterine muscle is unclear, magnesium sulfate does promote relaxation of smooth muscles
(Iams, 2002; Witcher, 2002). At the onset of preterm labor,
magnesium sulfate is administered via an intravenous infusion. Terbutaline, 0.25 mg, may be injected subcutaneously
before the initiation of the magnesium sulfate infusion and
then administered again by subcutaneous pump as the infusion is discontinued and the woman prepared for discharge
to home care (see Medication Guide).
Ritodrine and terbutaline, beta-adrenergic agonist medications for tocolysis, work by relaxing uterine smooth muscle as a result of stimulation of beta2 receptors on uterine
smooth muscle. Although seldom used, ritodrine is usually
administered intravenously as one of the first steps in suppressing preterm labor. Terbutaline is most commonly administered by a subcutaneous injection of 0.25 mg to sup-
24
Labor and Birth at Risk
777
BOX 24-6
Nursing Care for Women Receiving
Tocolytic Therapy
•
•
•
•
•
•
•
•
•
Explain the purpose and side effects of tocolytic therapy to woman and her family.
Position woman on her side to enhance placental perfusion and reduce pressure on the cervix.
Monitor maternal vital signs, fetal heart rate, and labor
status according to hospital protocol and professional
standards.
Assess mother and fetus for signs of adverse reactions
related to the tocolytic being administered.
Determine maternal fluid balance by measuring daily
weight and intake and output (I&O).
Limit fluid intake to 2500 to 3000 ml/day, especially if
a beta-adrenergic agonist is being administered.
Provide psychosocial support and opportunities for
women and family to express feelings and concerns.
Offer comfort measures as required.
Encourage diversional activities and relaxation techniques.
press uterine hyperactivity or by a subcutaneous pump. Effectiveness of pump therapy in prolonging gestation is controversial. Terbutaline also may be administered orally. Oral
and pump therapy are similar in terms of effectiveness and
adverse reactions (Witcher, 2002).
Beta2-adrenergic agonists have many maternal and fetal
cardiopulmonary and metabolic adverse reactions in part related to beta1 stimulation and must always be used with extreme caution and careful, conscientious nursing care. Fewer
neonatal adverse reactions occur if the administration of the
beta-adrenergic agonist is discontinued at least 4 hours before birth (Witcher, 2002). Medication administration and
nursing care are aimed at maintaining a therapeutic level of
medication and avoiding the most serious side effects while
maintaining optimal health of the fetus (see Medication
Guide).
BOX 24-5
Contraindications to Tocolysis
MATERNAL
•
•
•
•
•
Severe preeclampsia or eclampsia
Active vaginal bleeding
Intrauterine infection
Cardiac disease
Medical or obstetric condition that contraindicates continuation of pregnancy
FETAL
•
•
•
•
•
•
•
Estimated gestational age over 37 weeks
Dilation over 4 cm
Fetal demise
Lethal fetal anomaly
Chorioamnionitis
Acute fetal distress
Chronic intrauterine growth restriction
NURSE ALERT Caution must be used when administering intravenous fluids to women in preterm labor
because this practice can increase the risk for tocolyticinduced pulmonary edema, especially when a betaadrenergic agonist or magnesium sulfate is used. It
is recommended that the total oral and intravenous fluid
intake in 24 hours be restricted to 1500 to 2400 ml. Strict
intake and output measurement, daily weight determination, and assessment of pulmonary function should
be instituted (Gilbert & Harmon, 2003; Witcher, 2002).
Nifedipine, a calcium channel blocker, is another tocolytic
agent that can suppress contractions. It works by inhibiting
calcium from entering smooth muscle cells, thus reducing
uterine contractions (Lehne, 2001). Mild maternal side effects and ease of administration have increased its use. When
the tocolytic effects and maternal tolerance of nifedipine and
beta-adrenergic agonists were compared, no significant
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Medication Guide
Tocolytic Therapy for Preterm Labor
MEDICATION
AND ACTION
Magnesium sulfate*
DOSAGE
AND ROUTE
CNS depressant; relaxes smooth muscles including uterus
Mix 40 g in 1000 ml intravenous solution, piggyback to primary infusion, and administer
loading dose or bolus
of 4-6 g using controller pump over 15 to
20 min
Continue maintenance
infusion at 1 g/hr, increasing to a maximum 3 g/hr until contractions stop or
intolerable adverse reactions develop
ADVERSE
REACTIONS
NURSING
CONSIDERATIONS
During loading dose:
Hot flushes, sweating,
nausea and vomiting,
drowsiness, and blurred
vision; usually subside
when loading dose is
completed
Intolerable adverse reactions:
• Respiratory rate less than
12 breaths/min
• Absent DTRs
• Severe hypotension
• Extreme muscle weakness
• Urine output less than
25-30 ml/hr
• Serum magnesium level
of 10 mEq/L or greater
Assess woman and fetus before and after each rate increase and following frequency of agency protocol
Monitor serum magnesium
levels; therapeutic level
should range between
4 and 7.5 mEq/L
Discontinue infusion and notify physician if intolerable
adverse reactions occur
Ensure that calcium gluconate is available for
emergency administration
to reverse magnesium sulfate toxicity
Limit IV fluid intake to
125 ml/hr
•
Terbutaline* (Brethine)
Beta-adrenergic agonist
relaxes smooth muscles, inhibiting uterine activity and causing bronchodilation
Subcutaneous injection:
0.25 mg q30min for
2 hr
• Maximum dose:
0.5 mg q4-6h
Subcutaneous pump:
• Maintenance dose
0.05-0.1 mg/hr
• Bolus: 0.25 mg q4-6h
according to contraction pattern
• 3 mg/24 hr maximum
dose
Similar to ritodrine
•
Teach woman and family:
Assessment measures:
pulse, BP, respiratory effort, insertion site for infection, signs of PTL, and adverse reactions of
terbutaline
• Whom to call if problems
or concerns arise
• Site care and pump maintenance
• Activity restrictions
Arrange for follow-up and
home care
•
Nifedipine* (Procardia; Adalat)
Calcium channel
blocker; relaxes
smooth muscles including the uterus by
blocking calcium
entry
Initial dose: 10-20 mg PO
Maintenance dose: 10 to
20 mg q4-6h PO
differences in length of delay of birth were found, but significantly fewer maternal side effects occurred with nifedipine. Maternal side effects relate primarily to hypotension that
occurs with administration. Concerns regarding adverse fetal effects have been reduced. Safety is achieved by following recommended dosages and maintaining maternal
blood pressure, thereby preserving effective uteroplacental
Transient tachycardia,
palpitations
Hypotension
Dizziness, headache,
nervousness
Peripheral edema
Fatigue
Nausea
Facial flushing
Do not use with magnesium
sulfate
Assess woman and fetus according to agency protocol
being alert for adverse
reactions
Do not use sublingual route
perfusion (Iams & Creasy, 2004; Witcher, 2002) (see Medication Guide).
Indomethacin, a nonsteroidal antiinflammatory drug
(NSAID), has been shown in some trials to suppress preterm
labor by blocking the production of prostaglandins. Two
prostaglandins are affected, prostacyclin and thromboxane.
The decrease in prostacyclin suppresses uterine contractions,
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779
Medication Guide—cont’d
Tocolytic Therapy for Preterm Labor
MEDICATION
AND ACTION
Ritodrine (Yutopar)
DOSAGE
AND ROUTE
ADVERSE
REACTIONS
NURSING
CONSIDERATIONS
Beta-adrenergic agonist;
relaxes smooth muscles, inhibiting uterine activity and causing bronchodilation
Mix 150 mg in 500 ml
isotonic intravenous
solution
Attach to controller
pump and piggyback
to primary infusion
Begin infusion at 0.05-0.1
mg/min
Increase rate by 0.05 mg
q10min until contractions stop, intolerable
adverse reactions develop, or a maximum
dose of 0.35 mg/min is
reached
Maintain effective dose
for 12-24 hr
Intravenous adverse reactions:
• Shortness of breath,
coughing, tachypnea,
pulmonary edema
• Tachycardia, palpitations, skipped beats
• Chest pains
• Hypotension
• Tremors, dizziness,
nervousness
• Muscle cramps and
weakness
• Headache
• Hyperglycemia;
hypokalemia
• Nausea and vomiting
• Fetal tachycardia
Oral administration
adverse reactions:
• GI distress
• Significant adverse
effects are rare
Women should be screened
with ECG before therapy
begins; maternal heart disease and hypertension are
contraindications
Use cautiously if woman has
type 1 diabetes or hyperthyroidism
Validate that woman is in
PTL and that pregnancy is
over 20 weeks of gestation
Assess woman and fetus before and after each rate increase and following frequency of agency protocol
Discontinue infusion and notify physician if
• Maternal heart rate greater
than 120 to 140 beats/min;
dysrhythmias, chest pain
• BP is less than 90/60
mm Hg
• Fetal heart rate greater
than 180 beats/min
Ensure that propranolol (Inderal) is available to reverse adverse effects related to cardiovascular
function
Initial dose: 50 mg (orally
or rectally)
Maintenance dose: 25-50
mg, q4-6h for 24-48 hr
(PO)
Maternal: Nausea and
vomiting, dyspepsia,
dizziness, oligohyramnios
Fetal: Premature closure of ductus arteriosus
Neonate: Bronchopulmonary dysplasia,
respiratory distress
syndrome, intracranial hemorrhage,
necrotizing enterocolitis, hyperbilirubinemia
Used when other methods
fail; not recommended after 32 weeks of gestation
Do not use in women with
bleeding potential
Fetal assessment: amniotic
fluid level; function of ductus arteriosus
Indomethacin*
Prostaglandin inhibitor;
relaxes uterine
smooth muscle
*Caution: Not FDA approved for PTL (off-label use).
BP, Blood pressure; CNS, central nervous system; DTRs, deep tendon reflexes; ECG, electrocardiogram; GI, gastrointestinal; IV, intravenous; PO, by mouth; PTL, preterm labor.
and the decrease in thromboxane suppresses platelet aggregation. However, both of these actions increase the risk for
postpartum hemorrhage. The severity of fetal side effects associated with the use of indomethacin for tocolysis makes
it less common than other classes of tocolytic drugs. Risk for
premature closure of the ductus arteriosus increases if treat-
ment goes beyond 48 hours or if the fetus is aged 32 or more
weeks of gestation. Therefore, limiting the use of indomethacin to a short duration of treatment (e.g., 48 hours) or
to women with less than 32 weeks of gestation is recommended (Iams & Creasy, 2004; Witcher, 2002) (see Medication Guide).
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Promotion of fetal lung maturity
Antenatal glucocorticoids. Antenatal glucocorticoids given as intramuscular injections to the mother
accelerate fetal lung maturity. Such therapy is viewed as a
form of care likely to be beneficial (Enkin et al., 2000). The
National Institutes of Health consensus panel recommended
that all women at 24 to 34 weeks of gestation should be given
antenatal glucocorticoids when preterm birth is threatened,
unless there is a medical indication for immediate birth such
as cord prolapse, chorioamnionitis, or abruptio placentae
(National Institutes of Health, 2000). The regimen for administration of antenatal glucocorticoids is given in the Medication Guide.
NURSE ALERT Nurses need to know that when any
woman is admitted to the hospital and is 24 to 34 weeks
pregnant, she should receive antenatal glucocorticoids
unless she has chorioamnionitis. These drugs require a
24-hour period to become effective, so timely administration is essential.
Management of inevitable
preterm birth
Labor that has progressed to a cervical dilation of 4 cm
is likely to lead to inevitable preterm birth. Preterm births
in tertiary care centers lead to better neonatal and maternal
outcomes. Women considered at risk for inevitable preterm
birth should be transferred quickly to such a facility to ensure the best possible outcome. The first dose of antenatal
glucocorticoids should be given before transfer.
Although maternal transport helps to ensure a better
health outcome for the mother and the baby, it may have
complications. A woman may be transported to a tertiary
center far from home, making visits by the family difficult
and increasing the anxiety levels of the woman and her family. Attention to the needs of the woman and her family before, during, and after the transport is essential to comprehensive nursing care for these families.
Evaluation
Evaluation of the nursing care provided for a woman at risk
for preterm birth is based on achievement of the expected
outcomes of care (Plan of Care).
PRETERM PREMATURE
RUPTURE OF MEMBRANES
Premature rupture of membranes (PROM) is the rupture
of the amniotic sac and leakage of amniotic fluid beginning
at least 1 hour before the onset of labor at any gestational
age. Preterm premature rupture of membranes (PPROM)
(i.e., membranes rupture before 37 weeks of gestation) occurs in up to 25% of all cases of preterm labor. Infection often precedes PPROM, but the cause of PPROM remains unknown. PPROM is diagnosed after the woman reports of
Medication Guide
Antenatal Glucocorticoid Therapy
with Betamethasone, Dexamethasone
ACTION
•
Stimulates fetal lung maturation by promoting release
of enzymes that induce production or release of lung
surfactant. NOTE:The FDA has not approved these medications for this use (i.e., this is an off-label use for obstetrics).
INDICATION
•
To prevent or reduce the severity of respiratory distress
syndrome in preterm infants between 24 and 34 weeks
of gestation.
DOSAGE AND ROUTE
•
•
•
Betamethasone: 12 mg IM two doses 12 hr apart
Dexamethasone: 6 mg IM two doses 12 hr apart
May be repeated in 7 days if birth has not occurred.
ADVERSE REACTIONS
•
Possible maternal infection, pulmonary edema (if given
with beta-adrenergic medications), may worsen maternal condition (diabetes, hypertension).
NURSING CONSIDERATIONS
•
Give deep intramuscular injection in gluteal muscle.
Teach signs of pulmonary edema. Assess blood glucose levels and lung sounds. Do not give if woman has
infection. Use in women with preterm premature rupture of membranes (PPROM) not universally recommended.
IM, Intramuscularly.
either a sudden gush of fluid or a slow leak of fluid from the
vagina.
Infection is the serious side effect of PPROM that makes
it a major complication of pregnancy. Chorioamnionitis is
an intraamniotic infection of the chorion and amnion that
is potentially life threatening for the fetus and the woman.
Most cases of intrauterine infection respond well to antibiotics, yet sepsis can occur and can lead to maternal death.
Fetal complications from chorioamnionitis include congenital pneumonia, sepsis, and meningitis (Garite, 2004).
Even in the absence of infection, PPROM can precipitate
cord prolapse or cause oligohydramnios, leading to cord compression, potentially life-threatening complications for the
fetus.
Collaborative Care
Whenever PPROM is suspected, strict sterile technique
should be used in any vaginal examination to avoid introduction of infection. A nitrazine or fern test is used to determine if the discharge is amniotic fluid or urine (see Chapter 14: Procedure box: Tests for Rupture of Membranes). A
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PLAN OF CARE
•
•
Nursing Interventions/Rationales
•
•
•
Assess what the partners know about abnormal signs and
symptoms during pregnancy to identify areas of deficit.
Discuss signs and symptoms that serve as warning signs of
preterm labor so that the woman or her partner has adequate
information to identify problems early.
Provide written supplemental materials that include a list of
warning signs and instructions regarding what to do if any
of the listed signs occur so that the couple can reinforce and
review learning and act swiftly and appropriately should a
sign occur.
Discuss and demonstrate how to assess and time the contractions to provide needed skills to assess the signs of labor.
NURSING DIAGNOSIS Risk for maternal or fetal
injury related to recurrence of preterm labor
Expected Outcome Woman demonstrates ability to
assess self and fetus for signs of recurring labor;
maternal-fetal well-being is maintained.
Nursing Interventions/Rationales
•
•
•
•
•
•
•
•
•
•
Labor and Birth at Risk
781
Preterm Labor
NURSING DIAGNOSIS Deficient knowledge related to recognition of preterm labor
Expected Outcome Woman and significant other
delineate the signs and symptoms of preterm
labor.
•
24
Teach woman and partner how to monitor fetal and uterine
contraction activity daily to provide immediate evidence of
a worsening condition.
Have woman or partner report rupture of membranes, vaginal bleeding, cramping, pelvic pressure, or low backache to
appropriate health care resource immediately because such
symptoms are signs of labor.
If home uterine activity monitoring is to be used, teach
woman and partner how to use the monitoring device and
how to transmit the data to the health care provider via telephone to enhance correct use of monitoring device and increase the accuracy of detection of early labor.
Have woman monitor her weight, diet, fluid intake, and vital signs on a daily basis to evaluate for potential problems.
Limit activities to bed rest with bathroom privileges to decrease the likelihood of onset of labor.
Use a side-lying position to enhance placental perfusion.
Abstain from sexual intercourse and nipple stimulation because such activities may stimulate uterine contractions.
Practice relaxation techniques to decrease uterine tone and
decrease anxiety and stress.
Take tocolytic or other medications per physician’s orders to
inhibit uterine contractions.
Teach woman and partner about and have them report any
medication side effects immediately to prevent medicationinduced complications.
woman with this diagnosis can be cared for at home, with
more frequent visits to her primary health care provider (Patient Instructions for Self-Care box). Expectant management
will continue as long as there are no signs of infection or fetal distress. Nursing support of the woman and her family
is critical at this time. She is often anxious about the health
of her baby and may fear that she was responsible in some
Have family arrange for alternative strategies for carrying out
the woman’s usual roles and functions to decrease stress and
limit temptations to increase activity.
If small children are part of the household, encourage family to make alternative arrangements for child care to enhance
woman’s adherence to bed rest protocol.
NURSING DIAGNOSIS Anxiety related to preterm
labor and potentially premature neonate
Expected Outcome Feelings and symptoms of fear
or anxiety abate.
Nursing Interventions/Rationales
•
•
•
•
•
•
Provide a calm, soothing atmosphere and teach family to provide emotional support to facilitate coping.
Encourage verbalization of fears to decrease intensity of emotional response.
Involve woman and family in the home management of her
condition to promote a greater sense of control.
Help the woman identify and use appropriate coping strategies and support systems to reduce fear and anxiety.
Explore the use of desensitization strategies such as progressive muscle relaxation, visual imagery, or thought stopping to reduce fear-related emotions and related physical
symptoms.
Provide information about online support groups to reduce
fear and anxiety.
NURSING DIAGNOSIS Deficient diversional activity related to imposed bed rest
Expected Outcome Verbalization of diminished feelings of boredom.
Nursing Interventions/Rationales
•
•
•
•
•
•
Assist woman to creatively explore personally meaningful
activities that can be pursued from the bed to ensure activities that have meaning, purpose, and value to the individual.
Maintain emphasis on personal choices of the woman because doing so promotes control and minimizes imposition
of routines by others.
Evaluate what support and system resources are available
in the environment to assist in providing diversional activities.
Explore ways for the woman to remain an active participant
in home management and decision making to promote
control.
Engage support of family and friends in carrying out chosen
activities and making necessary environmental alterations to
ensure success.
Teach woman about stress management and relaxation techniques to help manage tension of confinement.
way for the membrane rupture. The nurse should encourage expression of feelings and concerns, provide information,
and make referrals as needed (Weitz, 2001).
Frequent biophysical profiles (BPPs) are performed to determine fetal health status and estimate amniotic fluid volume (AFV). The woman with PPROM also should be taught
how to count fetal movements daily, because a slowing of
CD: Plan of Care—Preterm Labor
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PATIENT INSTRUCTIONS
FOR SELF-CARE
The Woman with Preterm
Premature Rupture of Membranes
•
•
•
•
•
•
•
•
•
•
•
•
Take your temperature and assess pulse every 4 hours
when awake.
Report temperature of more than 38° C.
Remain on modified bed rest.
Insert nothing in the vagina.
Do not engage in sexual activity.
Assess for uterine contractions.
Do fetal movement counts daily.
Do not take tub baths.
Watch for foul-smelling vaginal discharge.
Wipe front to back after urinating or having a bowel
movement.
Take antibiotics if prescribed.
See primary health care provider as scheduled.
PATIENT INSTRUCTIONS
FOR SELF-CARE
Counting Fetal Movements
(Kick Counts)
•
•
Choose a time of day when you can sit or lie on your
side quietly.
Choices for counting strategies:
—Starting at 9 AM, count the baby’s movements until
you have counted 10. If you have not counted 10
movements in 12 hours, notify your primary health
care provider.
—Count four movements, three times a day after
meals. Most people count four movements in 1 hour.
If you don’t, then count for 1 more hour. If at the end
of 2 hours you still haven’t felt four movements, call
your primary health care provider.
fetal movement has been shown to be a precursor to severe
fetal compromise. Several methods are commonly used to
count fetal movements; two methods are described in the
Patient Instructions for Self-Care box. Antenatal glucocorticoids may be administered if chorioamnionitis is absent
(Weitz, 2001).
Vigilance for signs of infection is a major part of the nursing care and patient education after PPROM. The woman
must be taught how to keep her genital area clean and that
nothing should be introduced into her vagina. Signs of infection (e.g., fever, foul-smelling vaginal discharge, rapid
pulse) should be reported to the primary health care
provider immediately. Prophylactic antibiotic therapy may
be ordered in an effort to improve perinatal outcome by preventing infection (Garite, 2004). However, use of prophylactic antibiotics for PROM before labor at term or preterm
is a form of care of unknown effectiveness (Enkin et al.,
2000).
DYSTOCIA
Dystocia is defined as long, difficult, or abnormal labor; it
is caused by various conditions associated with the five factors affecting labor. It is estimated that dystocia occurs in approximately 8% to 11% of all births and is the primary cause
for cesarean births (Gregory, 2000). Dystocia can be caused
by any of the following:
Dysfunctional labor, resulting in ineffective uterine
contractions or maternal bearing-down efforts (the
powers). This is the most common cause of dystocia
(Cunningham et al., 2005).
Alterations in the pelvic structure (the passage).
Fetal causes, including abnormal presentation or position, anomalies, excessive size, and number of fetuses
(the passenger).
Maternal position during labor and birth.
Psychologic responses of the mother to labor related
to past experiences, preparation, culture and heritage,
and support system.
These five factors are interdependent. In assessing the
woman for an abnormal labor pattern, the nurse must consider the way in which these factors interact and influence
labor progress. Dystocia is suspected when there is an alteration in the characteristics of uterine contractions, a lack
of progress in the rate of cervical dilation, or a lack of
progress in fetal descent and expulsion.
•
•
•
•
•
Dysfunctional Labor
Dysfunctional labor is described as abnormal uterine contractions that prevent the normal progress of cervical dilation, effacement (primary powers), or descent (secondary
powers). Gilbert and Harmon (2003) cited several factors that
seem to increase a woman’s risk for uterine dystocia including the following:
Body build (e.g., 30 pounds or more overweight, short
stature)
Uterine abnormalities (e.g., congenital malformations;
overdistention, as with multiple gestation; or hydramnios)
Malpresentations and positions of the fetus
Cephalopelvic disproportion (CPD) (see p. 785)
Overstimulation with oxytocin
Maternal fatigue, dehydration and electrolyte imbalance, and fear
Inappropriate timing of analgesic or anesthetic administration
Dysfunction of uterine contractions can be further described as being hypertonic or hypotonic.
•
•
•
•
•
•
•
Hypertonic uterine dysfunction
The woman experiencing hypertonic uterine dysfunction,
or primary dysfunctional labor, often is an anxious first-time
mother who is having painful and frequent contractions that
are ineffective in causing cervical dilation or effacement to
progress. These contractions usually occur in the latent stage
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(cervical dilation of less than 4 cm) and are usually uncoordinated (Fig. 24-3). The force of the contractions may be
in the midsection of the uterus rather than in the fundus,
and the uterus is therefore unable to apply downward pressure to push the presenting part against the cervix. The uterus
may not relax completely between contractions (Gilbert &
Harmon, 2003).
Women with hypertonic uterine dysfunction may be exhausted and express concern about loss of control because
of the intense pain they are experiencing and the lack of
progress. Therapeutic rest, which is achieved with a warm
bath or shower and the administration of analgesics such as
morphine, meperidine (Demerol), or nalbuphine (Nubain)
to inhibit uterine contractions, reduce pain, and encourage
sleep, is usually prescribed for the management of hypertonic
uterine dysfunction. After a 4- to 6-hour rest, affected women
are likely to awaken in active labor with a normal uterine
contraction pattern (Gilbert & Harmon, 2003).
Hypotonic uterine dysfunction
The second and more common type of uterine dysfunction is hypotonic uterine dysfunction, or secondary
uterine inertia. The woman initially makes normal progress
into the active stage of labor; then the contractions become
weak and inefficient or stop altogether (see Fig. 24-3). The
uterus is easily indented, even at the peak of contractions.
Intrauterine pressure (IUP) during the contraction (usually
less than 25 mm Hg) is insufficient for progress of cervical
effacement and dilation (Gilbert & Harmon, 2003). CPD
and malpositions are common causes of this type of uterine dysfunction.
(mm Hg)
50
25
0
B
50
25
0
C
D
E
Intrauterine pressure
A
50
25
0
50
25
0
50
25
0
Time (min)
Fig. 24-3 Uterine contractility patterns in labor. A,Typical
normal labor. B, Subnormal intensity, with frequency greater
than needed for optimum performance. C, Normal contractions but too infrequent for efficient labor. D, Incoordinate activity. E, Hypercontractility.
24
Labor and Birth at Risk
783
A woman with hypotonic uterine dysfunction may become exhausted and be at increased risk for infection. Management usually consists of performing an ultrasound or
radiographic examination to rule out CPD and assessing the
fetal heart rate (FHR) and pattern, characteristics of amniotic
fluid if membranes are ruptured, and maternal well-being.
If findings are normal, then measures such as ambulation,
hydrotherapy, enema, stripping or rupture of membranes,
nipple stimulation, and oxytocin infusion can be used to
augment labor.
Secondary powers
Secondary powers, or bearing-down efforts, are compromised when large amounts of analgesia are given. Anesthesia may also block the bearing-down reflex and, as a
result, alter the effectiveness of voluntary efforts. Exhaustion resulting from lack of sleep or long labor and fatigue
resulting from inadequate hydration and food intake reduce the effectiveness of the woman’s voluntary efforts.
Maternal position can work against the forces of gravity
and decrease the strength and efficiency of the contractions.
Table 24-1 summarizes the characteristics of dysfunctional
labor.
Abnormal labor patterns
In 2002, prolonged labor patterns occurred at the rate of
7.0 per 1000 live births, with the incidence highest among
women under 20 years of age (8.1 per 1000) (Martin et al.,
2003).
Six abnormal labor patterns were identified and classified
by Friedman (1989) according to the nature of the cervical
dilation and fetal descent. The labor patterns seen in normal
and abnormal labor are described in Table 24-2.
These patterns may result from a variety of causes, including ineffective uterine contractions, pelvic contractures,
CPD, abnormal fetal presentation or position, early use of
analgesics, nerve block analgesia or anesthesia, and anxiety
and stress. Progress in either the first or second stage of labor can be protracted (prolonged) or arrested (stopped). Abnormal progress can be identified by plotting cervical dilation and fetal descent on a labor graph (partogram) at various
intervals after the onset of labor and comparing the resulting curve with the expected labor curve for a nulliparous or
multiparous labor (see Fig. 14-8, p. 415).
However, health care providers must be careful when diagnosing a labor pattern as prolonged and when intervening based on this diagnosis. Cesario (2004) found that although the average length of labor today is similar to that
found by Friedman, a wider range of normal labor occurs.
Parameters to determine if labor is progressing satisfactorily
may need to be expanded.
A long and difficult labor can have an adverse psychologic
effect on the mother, father, and family. Maternal morbidity and death may occur as a result of uterine rupture, infection, severe dehydration, and postpartum hemorrhage.
The fetus is at increased risk for hypoxia.
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TABLE 24-1
Dysfunctional Labor: Primary and Secondary Powers
HYPERTONIC
UTERINE DYSFUNCTION
HYPOTONIC
UTERINE DYSFUNCTION
INADEQUATE
VOLUNTARY EXPULSIVE FORCES
Cause may be pelvic contracture and
fetal malposition, overdistention of
uterus (e.g., twins), or unknown
(primary powers)
Involves abdominal and levator ani
muscles
Occurs in second stage of labor; cause
may be related to nerve block anesthetic, analgesia, exhaustion
DESCRIPTION
Usually occurs before 4 cm dilation;
cause unknown, may be related to
fear and tension (primary powers)
CHANGE IN PATTERN OF PROGRESS
Pain out of proportion to intensity of
contraction
Pain out of proportion to effectiveness
of contraction in effacing and dilating the cervix
Contractions increase in frequency
Contractions uncoordinated
Uterus is contracted between contractions, cannot be indented
Contractions decrease in frequency
and intensity
Uterus easily indentable even at peak
of contraction
Uterus relaxed between contractions
(normal)
No voluntary urge to push or bear
down or inadequate or ineffective
pushing
Infection
Exhaustion
Psychologic trauma
Spontaneous vaginal birth prevented;
assisted birth likely
POTENTIAL MATERNAL EFFECTS
Loss of control related to intensity of
pain and lack of progress
Exhaustion
POTENTIAL FETAL EFFECTS
Fetal asphyxia with meconium
aspiration
Fetal infection
Fetal and neonatal death
Fetal asphyxia
CARE MANAGEMENT
Initiate therapeutic rest measures
• Administer analgesic (e.g., morphine, nalbuphine, meperidine) if
membranes not ruptured or
cephalopelvic disproportion not
present
• Relieve pain to permit mother to
rest
• Assist with measures to enhance
rest and relaxation (e.g., hydrotherapy)
Rule out cephalopelvic disproportion
Stimulate labor with oxytocin (augmentation)
Perform amniotomy
Assist with measures to enhance the
progress of labor (e.g., position
changes, ambulation, hydrotherapy)
Precipitous labor. Precipitous labor is defined as
labor that lasts less than 3 hours from the onset of contractions to the time of birth. This abnormal labor pattern
occurred at a rate of 18.1 per 1000 live births in 2002. Precipitous labor occurred at the highest rate (21.9) among
women age 35 to 39 and at the lowest rate (11.7) among
women younger than 20 years old (Martin et al., 2003).
Precipitous labor may result from hypertonic uterine contractions that are tetanic in intensity. Maternal and fetal
complications can occur as a result. Maternal complications
include uterine rupture, lacerations of the birth canal, amniotic fluid embolism (AFE) ( p. 813), and postpartum hem-
Coach mother in bearing down with
contractions; assist with relaxation
between contractions
Position mother in favorable position
for pushing
Reduce epidural infusion rate
Assist with low forceps or vacuumassisted birth
Prepare for cesarean birth if nonreassuring fetal status occurs
orrhage. Fetal complications include hypoxia, caused by decreased periods of uterine relaxation between contractions,
and in rare instances, intracranial trauma related to rapid
birth (Cunningham et al., 2005).
Women who have experienced precipitous labor often describe feelings of disbelief that their labor began so quickly,
alarm that their labor progressed so rapidly, panic about the
possibility they would not make it to the hospital in time
to give birth, and finally relief when they arrived at the hospital. In addition, women have expressed frustration when
nurses did not believe them when they reported their readiness to push.
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TABLE 24-2
Labor Patterns in Normal
and Abnormal Labor
NORMAL LABOR
1. Dilation: continues
a. Latent phase: 4 cm and low slope
b. Active phase: 5 cm or high slope
c. Deceleration phase: 9 cm
2. Descent: active at 9 cm dilation
ABNORMAL LABOR
PATTERN
NULLIPARAS
MULTIPARAS
Prolonged latent
phase
Protracted active
phase dilation
Secondary arrest:
no change
Protracted descent
Arrest of descent
Failure of descent
20 hr
14 hr
1.2 cm/hr
1.5 cm/hr
2 hr
2 hr
Precipitous labor
1 cm/hr
2 cm/hr
1 hr
1⁄ 2 hr
No change during deceleration
phase and second stage
5 cm/hr
10 cm/hr
Alterations in Pelvic Structure
Pelvic dystocia
Pelvic dystocia can occur whenever there are contractures
of the pelvic diameters that reduce the capacity of the bony
pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.
Disproportion of the pelvis is the least common cause of
dystocia (Cunningham et al., 2005). Pelvic contractures may
be caused by congenital abnormalities, maternal malnutrition, neoplasms, or lower spinal disorders. An immature
pelvic size predisposes some adolescent mothers to pelvic
dystocia. Pelvic deformities also may be the result of automobile or other accidents or trauma.
An inlet contracture is diagnosed whenever the diagonal
conjugate is less than 11.5 cm. The incidence of face and
shoulder presentation is increased. Because these presentations interfere with engagement and fetal descent, the risk
of prolapse of the umbilical cord is increased. Inlet contracture is associated with maternal rickets and a flat pelvis.
Weak uterine contractions may be noted during the first
stage of labor in affected women.
Midplane contracture, the most common cause of pelvic
dystocia, is diagnosed whenever the sum of the interischial
spinous and posterior sagittal diameters of the midpelvis is
13.5 cm or less. Fetal descent is arrested (transverse arrest of
the fetal head) in such births because the head cannot rotate
internally. These infants are usually born by cesarean, but
vacuum-assisted birth has been used safely when the cervix
is fully dilated. Midforceps-assisted birth usually is not done
24
Labor and Birth at Risk
785
because of the increased perinatal morbidity associated with
this intervention.
Outlet contracture exists when the interischial diameter
is 8 cm or less. It rarely occurs in the absence of midplane
contracture. Women with outlet contracture have a long, narrow pubic arch and an android pelvis, and this causes fetal
descent to be arrested. Maternal complications include extensive perineal lacerations during vaginal birth because the
fetal head is pushed posteriorly.
Soft-tissue dystocia
Soft-tissue dystocia results from obstruction of the birth
passage by an anatomic abnormality other than that involving the bony pelvis. The obstruction may result from placenta previa (low-lying placenta) that partially or completely
obstructs the internal os of the cervix. Other causes, such as
leiomyomas (uterine fibroids) in the lower uterine segment,
ovarian tumors, and a full bladder or rectum, may prevent
the fetus from entering the pelvis. Occasionally cervical
edema occurs during labor when the cervix is caught between
the presenting part and the symphysis pubis or when the
woman begins bearing-down efforts prematurely, thereby inhibiting complete dilation. Sexually transmitted infections
(e.g., human papillomavirus) can alter cervical tissue integrity
and thus interfere with adequate effacement and dilation.
Bandl ring, a pathologic retraction ring that forms between the upper and lower uterine segments (see Fig. 11-10),
is associated with prolonged rupture of membranes, protracted labor, and increased risk for uterine rupture
(Cunningham et al., 2005).
Fetal Causes
Dystocia of fetal origin may be caused by anomalies, excessive fetal size and malpresentation, malposition, or multifetal pregnancy. Complications associated with dystocia of
fetal origin include neonatal asphyxia, fetal injuries or fractures, and maternal vaginal lacerations. Although spontaneous vaginal birth is possible in these instances, a low
forceps-assisted, vacuum-assisted, or cesarean birth often is
necessary.
Anomalies
Gross ascites, large tumors, and open neural tube defects
(e.g., myelomeningocele, hydrocephalus) are fetal anomalies
that can cause dystocia. The anomalies affect the relation of
the fetal anatomy to the maternal pelvic capacity, with the
result that the fetus is unable to descend through the birth
canal.
Cephalopelvic disproportion
Cephalopelvic disproportion (CPD), also called fetopelvic
disproportion (FPD), is often related to excessive fetal size (i.e.,
4000 g or more). When CPD is present, the fetus cannot fit
through the maternal pelvis to be born vaginally. Excessive
fetal size, or macrosomia, is associated with maternal diabetes
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mellitus, obesity, multiparity, or the large size of one or both
parents. If the maternal pelvis is too small, abnormally
shaped, or deformed, CPD may be of maternal origin. In this
case, the fetus may be of average size or even smaller.
Malposition
The most common fetal malposition is persistent occipitoposterior position (i.e., right occipitoposterior [ROP] or
left occipitoposterior [LOP]; see Chapter 11), occurring in
about 25% of all labors. Labor, especially the second stage,
is prolonged; the woman typically complains of severe back
pain from the pressure of the fetal head (occiput) pressing
against her sacrum. Box 24-7 identifies suggested measures
to relieve back pain and facilitate rotation of the fetal occiput
BOX 24-7
Back Labor—Occiput Posterior Position
MEASURES TO RELIEVE BACK PAIN AND
FACILITATE ROTATION OF FETAL HEAD
Measures to reduce back pain during a
contraction
•
•
•
•
Counterpressure: apply fist or heel of hand to sacral
area
Heat or cold applications: apply to sacral area
Double hip squeeze:
—Woman assumes a position with hip joints flexed,
such as knee-chest
—Partner, nurse, or doula places hands over gluteal
muscles and presses with palms of hands up and inward toward the center of the pelvis
Knee press:
—Woman assumes a sitting position with knees a few
inches apart and feet flat on the floor or on a stool
—Partner, nurse, or doula cups a knee in each hand
with heels of hands on top of tibia then presses the
knees straight back toward the woman’s hips
while leaning forward toward the woman
to an anterior position, which will facilitate birth (Gilbert &
Harmon, 2003; Simkin & Ancheta, 2000).
Malpresentation
Malpresentation is the third most commonly reported
complication of labor and birth. Breech presentation is the
most common form of malpresentation. The four main types
of breech presentation are frank breech (thighs flexed, knees
extended), complete breech (thighs and knees flexed), and
two types of incomplete breech, one in which the knee extends below the buttocks and the other in which the foot extends below the buttocks (Fig. 24-4). Breech presentations are
associated with multifetal gestation, preterm birth, fetal and
maternal anomalies, hydramnios, and oligohydramnios. Diagnosis is made by abdominal palpation (e.g., Leopold maneuvers) and vaginal examination and usually is confirmed
by ultrasound scan (Lanni & Seeds, 2002).
During labor, the descent of the fetus in a breech presentation may be slow because the breech is not so good a
dilating wedge as is the fetal head; the labor itself usually is
not prolonged. There is risk of prolapse of the cord if the
membranes rupture in early labor. The presence of meconium in amniotic fluid is not necessarily a sign of fetal distress because it results from pressure on the fetal abdominal
wall as it traverses the birth canal. Assessment of FHR and
pattern should be used to determine whether the passage of
meconium is an expected finding associated with breech
presentation or is a nonreassuring sign associated with fetal
hypoxia. The fetal heart tones of infants in a breech position
are best heard at or above the umbilicus.
A
B
C
D
Measures to facilitate the rotation of the fetal
head (may also relieve back pain)
•
•
•
•
•
•
•
Lateral abdominal stroking: stroke the abdomen in direction that the fetal head should rotate
Hands-and-knees position (all-fours): can also be accomplished by kneeling while leaning forward over a
birth ball, padded chair seat, bed, or over-the-bed table
Squatting
Pelvic rocking
Stair climbing
Lateral position: lie on side toward which the fetus
should turn
Lunges: widens pelvis on side toward which woman
lunges
—Woman stands, facing forward, next to or alongside
a chair so that she can lunge toward the side the fetal back is on or in the direction of the fetal occiput
—Places foot on seat of chair with toes pointed toward
the back of the chair, then lunges
—Alternative position for lunge: kneeling
Fig. 24-4 Types of breech presentation. A, Frank breech:
thighs are flexed on hips; knees are extended. B, Complete
breech: thighs and knees are flexed. C, Incomplete breech: foot
extends below the buttocks. D, Incomplete breech: knee extends below the buttocks.
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Labor and Birth at Risk
787
EVIDENCE-BASED PRACTICE
Planned Caesarean Birth versus Vaginal Birth for Term Breech Presentation
uled for cesarean births experienced significantly fewer
perinatal deaths (excluding fatal anomalies), decreased
short-term neonatal morbidity, fewer low Apgar (less than
7) or very low Apgar (less than 4) scores, less acidotic cord
blood, and less cord base excess (15 or more) than did
the planned vaginal birth group. The reduction in risk of
perinatal mortality and morbidity was less in countries
with high perinatal mortality rates. No difference in infant
birth trauma was noted between groups. A small but significant increase in short-term maternal morbidity was
found in the planned cesarean group. At 3 months postpartum the planned cesarean group experienced less urinary incontinence and perineal pain, and more abdominal pain, than the planned vaginal birth group.
BACKGROUND
•
Breech presentation at birth has been associated with nulliparity, previous breech, uterine or pelvic anomaly, placental malplacement, too much or too little amniotic fluid,
extended fetal legs, multiple pregnancy, preterm birth,
shortened umbilical cord, decreased fetal activity, intrauterine growth restriction (IUGR), fetal anomaly, and
stillbirth. Commonly, breech presentation is an indication
for a cesarean birth. Some researchers speculate that the
breech position itself is an indicator of poor outcome. For
example, the rate of childhood handicaps among breech
babies is high, no matter what method of birth is employed. In addition, cesarean birth exposes the mother
and baby to all the risks of operative procedures: anesthesia problems, infection, pain, delayed recovery, immobility, ileus, uterine rupture in future pregnancies, and
neonatal respiratory problems. Length of stay and cost
also rise considerably.
LIMITATIONS
•
OBJECTIVES
•
The reviewers sought to compare the maternal and perinatal outcomes of routine cesarean birth for term breech
presentation, compared with term breech presentations
delivered vaginally. The perinatal outcomes are death (excluding fatal anomalies), serious neonatal morbidity (Apgar score less than 7, cord blood pH less than 7.0, neonatal intensive care admission, birth asphyxia, birth trauma),
and disability in childhood. Maternal outcomes include
death, pain, incontinence, instrumental delivery, hemorrhage, infection, depression, self-esteem, relationship with
infant and family, problems with future pregnancies and
deliveries, satisfaction, and costs. All women should be
considered suitable for vaginal birth.
CONCLUSIONS
•
•
Search Strategy
•
The authors searched the Cochrane database, MEDLINE,
30 journals and conference proceedings, and a weekly
current awareness service of 37 journals. Search keyword
was breech.
Three randomized, controlled trials met the criteria, representing 2396 women. Two trials, dated 1980 and 1983,
were from the United States. The other trial, dated 2000,
was a large, international multicenter trial whose countries were not noted in the review.
Statistical Analyses
•
Similar data were pooled. Reviewers calculated relative
risks for dichotomous data, and weighted mean differences for continuous data. Countries with low (20 per
1000 or less) and high (more than 20 per 1000) perinatal
mortality rates were subgrouped for comparison.
There is evidence that planned caesarean birth in term
breech presentations is associated with decreased perinatal death and morbidity rates and an increase in shortterm maternal morbidity.
IMPLICATIONS FOR PRACTICE
METHODS
•
The two smaller U.S. studies from 1980 and 1983 did not
specify the method of randomization. One of those studies had a large discrepancy in numbers between groups.
The large multicenter trial used a wide variety of clinical
settings and had good follow-up rates, which were
strengths.
Planned caesarean birth is not always desirable or feasible in all settings. External cephalic version, or the
ultrasound-guided process of manually changing the fetal presentation from outside the abdomen, is one alternative. Promising results have been noted in other alternative practices, such as using various positions and
moxibustion. (Moxibustion is a method of producing
analgesia by holding slow-burning moxa or another substance near the skin without causing pain or burning;
sometimes used in conjunction with acupuncture.) Even
cesarean birth does not totally eliminate the problems associated with breech presentation. Diagnosis of the presentation before labor is desirable.
IMPLICATIONS FOR FURTHER RESEARCH
•
Much more evidence is needed on the effects of cesarean
births, for breech presentation or other indication, on
long-term outcomes, such as reproductive function of
women and child development. Researchers need to assess the psychologic impact of cesarean birth on women
and their adaptation to parenting. Cost was not addressed
in these trials but remains a primary factor in policy making and decision making.
FINDINGS
•
Of the women with term breech presentation allocated to
vaginal birth, 45% gave birth by cesarean. Those sched-
Reference: Hofmeyr, G., & Hannah, M. (2003). Planned caesarean section for term breech delivery (Cochrane Review). In The Cochrane Library, Issue 3, 2005. Chichester, UK: John
Wiley & Sons.
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Vaginal birth is accomplished by mechanisms of labor
that manipulate the buttocks and lower extremities as they
emerge from the birth canal (Fig. 24-5). Piper forceps sometimes are used to deliver the head. External cephalic version
(ECV) (see later discussion ) may be tried to turn the fetus
to a vertex presentation (Fig. 24-6). Cesarean birth may be
necessary (Bowes & Thorp, 2004).
Although opinions vary, a cesarean birth is commonly
performed when the fetus is estimated to be larger than
3800 g or smaller than 1500 g, if this is a first pregnancy, if
labor is ineffective, or if complications occur. Although cesarean birth reduces the risks to the fetus, the maternal risks
are increased. ECV also poses risks and is not always successful. Women whose breech presentation occurs late in
pregnancy need to be informed of the options for birth, as
well as the risks associated with each option.
Face and brow presentations are uncommon and are associated with fetal anomalies, pelvic contractures, and CPD.
Vaginal birth is possible if the fetus flexes to a vertex presentation, although forceps often are used. Cesarean birth
is indicated if the presentation persists, if there is fetal distress, or if labor stops progressing.
Cesarean birth is usually necessary for a fetus in a shoulder presentation (i.e., the fetus is in a transverse lie), although
ECV may be attempted after 38 weeks of gestation (Bowes
& Thorp, 2004).
Multifetal pregnancy
Multifetal pregnancy is the gestation of twins, triplets,
quadruplets, or more infants. The twin birth rate was 31.1 per
A
1000 live births in 2002. The higher-order multiple birth rate
(i.e., triplet and more) was 184 per 100,000 live births in 2002
(Martin et al., 2003). The incidence of multiple births has
been increasing since 1980. It is likely that this trend is related to the use of fertility-enhancing medications and procedures and the older age of childbearing women. When
compared with younger women, women age 35 years and
older are naturally more likely to have a multifetal pregnancy.
Multiple births are associated with more complications
(e.g., dysfunctional labor) than are single births. The higher
incidence of fetal and newborn complications and higher risk
of perinatal mortality primarily stem from the birth of lowbirth-weight infants resulting from preterm birth and/or
IUGR in part related to placental dysfunction and twin-totwin transfusion. Fetuses may experience distress and asphyxia during the birth process as a result of cord prolapse
and the onset of placental separation with the birth of the
first fetus. As a result, the risk for long-term problems such
as cerebral palsy is higher among infants who were part of
a multiple birth.
In addition, fetal complications such as congenital anomalies and abnormal presentations can result in dystocia and
an increased incidence of cesarean birth. For example, in
only half of all twin pregnancies do both fetuses present
in the vertex position, the most favorable for vaginal birth;
in one third of the pregnancies, one twin may present in the
vertex position and one in the breech (Cunningham et al.,
2005).
The health status of the mother may be compromised by
an increased risk for hypertension, anemia, and hemorrhage
C
B
E
F
D
G
Fig. 24-5 Mechanism of labor in breech presentation. A, Breech before onset of labor. B, Engagement and internal rotation. C, Lateral flexion. D, External rotation or restitution. E, Internal rotation of shoulders and head. F, Face rotates to sacrum when occiput is anterior. G, Head is born
by gradual flexion during elevation of fetal body.
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A
B
Fig. 24-6 External version of fetus from breech to vertex
presentation. This must be achieved without force. A, Breech
is pushed up out of pelvic inlet while head is pulled toward
inlet. B, Head is pushed toward inlet while breech is pulled
upward.
associated with uterine atony, abruptio placentae, and multiple or adherent placentas. Duration of the phases and stages
of labor may vary from the duration experienced with singleton births.
Teamwork and planning are essential components of the
management of childbirth in multiple pregnancies, especially those of the higher-order multiples. The nurse plays
a key role in coordinating the activities of many highly
skilled health care professionals. Early detection and care of
the maternal, fetal, and newborn complications associated
with multiple births are essential to achieve a positive outcome for mother and babies. Maternal positioning and
active support are used to enhance labor progress and
placental perfusion. Stimulation of labor with oxytocin,
epidural anesthesia, forceps and vacuum assistance, and internal or external version may be used to accomplish the
vaginal birth of twins. Cesarean birth is most likely with
higher-order multiple births. Each infant may have its own
team of health care providers present at the birth. Emotional
support that includes expression of feelings and full explanations of events as they occur and of the status of the
mother and the fetuses and newborns is important to reduce
the anxiety and stress that the mother and her family experience.
24
Labor and Birth at Risk
789
Position of the Woman
The functional relationship among the uterine contractions,
the fetus, and the mother’s pelvis are altered by the maternal position. In addition, the position can provide either a
mechanical advantage or disadvantage to the mechanisms of
labor by altering the effects of gravity and the body-part relations important to the progress of labor. For example, the
hands-and-knees position facilitates rotation from a posterior occiput position more effectively than does the lateral
position. Upright positions such as sitting and squatting facilitate fetal descent during pushing and shorten the second
stage of labor (Mayberry et al., 2000; Simkin & Ancheta,
2000). Discouraging maternal movement or restricting labor
to the recumbent or lithotomy position may compromise
progress. The incidence of dystocia in women confined to
these positions is increased, resulting in increased need for
augmentation of labor or forceps-assisted, vacuum-assisted,
or cesarean birth.
Psychologic Responses
Hormones and neurotransmitters released in response to
stress (e.g., catecholamines) can cause dystocia. Sources
of stress vary for each woman, but pain and the absence
of a support person are two recognized factors. Confinement to bed and restriction of maternal movement can be
a source of psychologic stress that compounds the physiologic stress caused by immobility in the unmedicated laboring woman. When anxiety is excessive, it can inhibit
cervical dilation and result in prolonged labor and increased pain perception. Anxiety also causes increased levels of stress-related hormones (e.g., beta-endorphin, adrenocorticotropic hormone, cortisol, and epinephrine). These
hormones act on the smooth muscles of the uterus; increased levels can cause dystocia by reducing uterine contractility.
CARE MANAGEMENT
Assessment and Nursing
Diagnoses
Risk assessment is a continuous process in the laboring
woman. Review of the findings obtained during the initial
interview conducted at the woman’s admission to the labor
unit and ongoing observations of her psychologic response
to labor may reveal factors that can be a source of dysfunctional labor. These factors may include anxiety or fear,
a complication of pregnancy, or previous labor complications. The initial physical assessment and ongoing assessments provide information about maternal well-being;
status of labor in terms of the characteristics of uterine contractions and progress of cervical effacement and dilation;
fetal well-being in terms of FHR and pattern, presentation,
station, and position; and status of the amniotic membranes.
Ultrasound scanning can identify potential dysfunctional
labor problems related to the fetus or maternal pelvis. All
these assessments contribute to accurate identification of
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potential and actual nursing diagnoses related to dystocia
and maternal-fetal compromise.
Nursing diagnoses that might be identified in women experiencing dystocia include the following:
•
•
•
•
Risk for maternal or fetal injury related to
—interventions implemented for dystocia
Powerlessness related to:
—loss of control
Risk for infection related to:
—PPROM
—operative procedures
Ineffective individual coping related to
—inadequate support system.
—exhaustion
—pain
Expected Outcomes of Care
Expected outcomes for the woman with dystocia include the
following. The woman will:
Understand the causes and treatment of dysfunctional
labor
Use measures recommended by the health care team
to enhance the progress of labor and birth
Express relief of pain
Experience labor and birth with minimal or no complications, such as infection, injury, or hemorrhage
Give birth to a healthy infant who has experienced no
fetal distress or birth injury
•
•
•
•
•
Plan of Care and Interventions
Nurses assume many caregiving roles when labor is complicated. They also work collaboratively with other health
care providers in providing care. Interventions that the nurse
may implement or assist with include ECV, trial of labor, cervical ripening with prostaglandins, induction or augmentation with oxytocin, amniotomy, and operative procedures
(e.g., forceps- or vacuum-assisted birth). The nursing role is
identified with each of the procedures described.
LEGAL TIP
Standard of Care—Labor and Birth
Complications
• Document all assessment findings, interventions, and
patient responses on patient record and monitor
strips according to unit protocols, procedures, and
policies and professional standards.
• Assess whether the woman (and her family, if appropriate) is fully informed about procedures for
which she is consenting.
• Provide full explanations regarding what is happening and what needs to be done to help her and her
baby (see Guidelines/Guías boxes: Induction of Labor,
p. 791, and Cesarean Birth, p. 802).
• Maintain safety by administering medications and
treatments correctly.
• Have verbal orders signed as soon as possible.
• Provide care at the acceptable standard (e.g., according to hospital protocols and professional standards).
• If short staffing occurs in the unit and the nurse is assigned additional patients, the nurse should document that rejecting this additional assignment would
have placed these patients in danger as a result of
abandonment.
• Maternal and fetal monitoring continues until birth according to the policies, procedures, and protocols of
the birthing facility, even when a decision to carry out
cesarean birth is made.
Version
Version is the turning of the fetus from one presentation
to another and may be done either externally or internally
by the physician.
External cephalic version. External cephalic
version (ECV) is used to attempt to turn the fetus from a
breech or shoulder presentation to a vertex presentation for
birth. It may be attempted in a labor and birth setting after 37 weeks of gestation. ECV is accomplished by the exertion of gentle, constant pressure on the abdomen (see Fig.
24-6). Before ECV is attempted, ultrasound scanning is
done to determine the fetal position; locate the umbilical
cord; rule out placenta previa; evaluate the adequacy of the
maternal pelvis; and assess the amount of amniotic fluid,
the fetal age, and the presence of any anomalies. A nonstress test (NST) is performed to confirm fetal well-being,
or the FHR pattern is monitored for a period of time (e.g.,
10 to 20 minutes). Informed consent is obtained. A tocolytic agent such as magnesium sulfate or terbutaline often is given to relax the uterus and to facilitate the maneuver (Bowes & Thorp, 2004). Factors that are associated
with unsuccessful version include maternal obesity, oligohydramnios, deep engagement of the buttocks, and posterior position of the fetal back. ECV is controversial in women who have had a previous cesarean birth (Cunningham
et al., 2005; Lanni & Seeds, 2002). ECV performed at term
to avoid breech birth is a beneficial form of care (Enkin et
al., 2000).
During an attempted ECV, the nurse continuously monitors the FHR and pattern, especially for bradycardia and
variable decelerations; checks the maternal vital signs; and
assesses the woman’s level of comfort because the procedure
may cause discomfort. After the procedure is completed, the
nurse continues to monitor maternal vital signs, uterine activity, and FHR and pattern and to assess for vaginal bleeding until the woman’s condition is stable. Women who are
Rh negative should receive Rh immune globulin because the
manipulation can cause fetomaternal bleeding (Bowes &
Thorp, 2004).
Internal version. With internal version, the fetus is
turned by the physician, who inserts a hand into the uterus
and changes the presentation to cephalic (head) or podalic
(foot). Internal version may be used in multifetal pregnancies to deliver the second fetus. The safety of this procedure
has not been documented; maternal and fetal injury is possible. Cesarean birth is the usual method for managing malpresentation in multifetal pregnancies. The nurse’s role is to
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monitor the status of the fetus and to provide support to the
woman.
Trial of labor
A trial of labor (TOL) is the observance of a woman and
her fetus for a reasonable period (e.g., 4 to 6 hours) of spontaneous active labor to assess safety of vaginal birth for the
mother and infant. It may be initiated if the mother’s pelvis
is of questionable size or shape, if the fetus is in an abnormal presentation, or if the woman wishes to have a vaginal
birth after a previous cesarean birth. It is a form of care likely
to be beneficial when implemented after a previous lowsegment cesarean birth (Enkin et al., 2000). Fetal sonography, maternal pelvimetry, or both may be done before a
TOL to rule out CPD. The cervix must be ripe (e.g., soft, dilatable). During a TOL, the woman is evaluated for the occurrence of active labor, including adequate contractions, engagement and descent of the presenting part, and effacement
and dilation of the cervix.
The nurse assesses maternal vital signs and FHR and pattern and is alert for signs of potential complications. If complications develop, the nurse is responsible for initiating appropriate actions, including notifying the primary health care
provider, and for evaluating and documenting the maternal
and fetal responses to the interventions. Nurses must recognize that the woman and her partner are often anxious
about her health and well-being and that of their baby. Supporting and encouraging the woman and her partner and
providing information regarding progress can reduce stress,
enhance the labor process, and facilitate a successful outcome.
Induction of labor
Induction of labor is the chemical or mechanical initiation of uterine contractions before their spontaneous onset
for the purpose of bringing about the birth (Guidelines/
Guías: Induction of Labor). Induction may be indicated for
a variety of medical and obstetric reasons. These include
preeclampsia, diabetes mellitus, chorioamnionitis, and other
medical problems, PROM, postterm pregnancy, suspected
fetal jeopardy (e.g., IUGR), logistic factors such as history
24
Labor and Birth at Risk
791
of previous rapid birth or distance of the woman’s home
from the hospital, and fetal death. Under such conditions
the risk to the mother or fetus is less than the risk of continuing the pregnancy (Bowes & Thorp, 2004). Two thirds
of the inductions in the United States are elective (i.e., for
the convenience of the woman or the health care practitioner) (Ramsey, Ramin, & Ramin, 2000).
Both chemical and mechanical methods are used to induce labor. Intravenous oxytocin and amniotomy are the
most common methods used in the United States. Prostaglandins are increasingly used for inducing labor. The most
effective protocol (e.g., dose, frequency) to follow when using prostaglandins continues to be investigated (Simpson,
2002; Simpson & Atterbury, 2003).
Less commonly used methods include stripping of membranes, nipple stimulation (manual or with a breast pump),
and acupuncture (Bowes & Thorp, 2004). The ingestion of
a laxative (e.g., castor oil), herbal preparations (e.g., green,
chamomile, or raspberry tea; blue or black cohosh), or spicy
food and administration of a soapsuds enema are other
methods (Simpson, 2002). Many folk beliefs exist regarding
methods to induce labor. These methods include activity
(e.g., walking, exercise, strenuous work, intercourse), fasting,
and increasing stress (e.g., frightening the woman). It is important for the nurse to know the practices a woman may
believe in and follow, because some of these methods can
be harmful (e.g., strenuous activity) (Schaffir, 2002).
Success rates for induction of labor are higher when the
condition of the cervix is favorable, or inducible. A rating
system such as the Bishop score (Table 24-3) can be used to
evaluate inducibility. For example, a score of 9 or more on
this 13-point scale indicates that the cervix is soft, anterior,
50% or more effaced, and dilated 2 cm or more; and that
the presenting part is engaged. Induction of labor is likely
to be more successful if the score is 9 or more for nulliparas
and 5 or more for multiparas (Gilbert & Harmon, 2003).
Cervical ripening methods
Chemical agents. A prostaglandin E2 gel (a cervical
ripening agent) was approved by the FDA in 1993. Preparations of prostaglandin E1 and prostaglandin E2 can be used
before induction to “ripen” (soften and thin) the cervix
(Medication Guides). This treatment usually results in a
GUIDELINES/GUÍAS
Induction of Labor
•
•
•
•
•
•
•
•
Your labor is not progressing.
Su trabajo de parto no está progresando.
We need to stimulate the contractions.
Necesitamos provocar las contracciones.
I’m going to give you some medication to make your
contractions stronger.
Le voy a dar una medicina para hacer más fuertes las
contracciones.
I’m going to give you Pitocin through your intravenous
line.
Le voy a dar pitufina por medio del suero.
TABLE 24-3
Bishop Score
Dilation (cm)
Effacement
(%)
Station (cm)
Cervical
consistency
Cervix
position
SCORE
2
0
1
0
0-30
1-2
40-50
3
Firm
2
1
Medium Soft
3-4
60-70
3
5
80
1,2
Soft
Posterior MidAnterior Anterior
position
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Medication Guide
Cervical Ripening Using Prostaglandin
E1 (PGE1): Misoprostol (Cytotec)
NURSING CONSIDERATIONS
•
ACTION
•
PGE1 ripens the cervix, making it softer and causing it to
begin to dilate and efface; stimulates uterine contractions.
•
INDICATIONS
•
PGE1 is used for preinduction cervical ripening (ripening
of cervix before oxytocin induction of labor when the
Bishop score is 4 or less) and to induce labor or abortion
(abortifacient agent).
DOSAGE
•
•
Insert 25 to 50 mcg (1⁄ 4 to 1⁄ 2 of a 100-mcg tablet) intravaginally into the posterior fornix using the tips of index and middle fingers without the use of a lubricant.
Repeat every 3 to 6 hours as needed to a maximum of
300 to 400 mcg in a 24-hour period or until an effective
contraction pattern is established (three or more uterine contractions in 10 minutes), the cervix ripens (Bishop
score of 8 or greater), or significant adverse reactions
occur.
Administer 50-100 mcg, PO q4-6h (GI effects increased;
may be less effective; data insufficient to recommend giving orally).
•
•
•
•
•
ADVERSE REACTIONS
•
Higher dosages are more likely to result in adverse reactions such as nausea and vomiting, diarrhea, fever,
tachysystole (12 or more uterine contractions in 20 minutes without alteration of FHR pattern), hyperstimulation
of the uterus (tachysystole with nonreassuring FHR patterns), or fetal passage of meconium.
•
•
•
Explain procedure to woman and her family. Ensure that
an informed consent has been obtained as per agency
policy.
Assess maternal-fetal unit, before each insertion and during treatment, following agency protocol for frequency.
Assess maternal vital signs and health status, FHR pattern, and status of pregnancy, including indications for
cervical ripening or induction of labor, signs of labor or
impending labor, and the Bishop score. Recognize that a
nonreassuring FHR pattern; maternal fever, infection,
vaginal bleeding, or hypersensitivity; and regular, progressive uterine contractions contraindicate the use of
misoprostol.
Use caution if the woman has a history of asthma, glaucoma, or renal, hepatic, or cardiovascular disorders.
Have woman void before procedure.
Assist woman to maintain a supine position with lateral
tilt or a side-lying position for 30 to 40 minutes after insertion.
Prepare to swab vagina to remove unabsorbed medication using a saline-soaked gauze wrapped around fingers
and to administer terbutaline 0.25 mg subcutaneously or
intravenously if significant adverse reactions occur.
Initiate oxytocin for induction of labor no sooner than
4 hours after last dose of misoprostol was administered,
following agency protocol, if ripening has occurred and
labor has not begun.
Document all assessment findings and administration
procedures.
Not recommended for use if woman has had previous cesarean birth or if she has a uterine scar.
Misoprostol (Cytotec) has not yet been approved by the
FDA for cervical ripening or labor induction.
FHR, Fetal heart rate; GI, gastrointestinal; PO, by mouth.
higher success rate for the induction of labor, the need for
lower dosages of oxytocin during the induction, and shorter
induction times. The use of prostaglandins to increase cervical readiness for induction of labor is a beneficial form of
care (Enkin et al., 2000). In some cases, women will go into
labor after the administration of prostaglandin, thereby eliminating the need to administer oxytocin to induce labor
(Gilbert & Harmon, 2003; Simpson, 2002). Prostaglandin E1,
although less expensive and more effective than oxytocin or
prostaglandin E2 for inducing labor and birth, is associated
with a higher risk for hyperstimulation of the uterus and
nonreassuring changes in FHR and pattern (Goldberg,
Greenberg, & Darney, 2001).
Mechanical methods. Mechanical dilators ripen the
cervix by stimulating the release of endogenous prostaglandins. Their use is a form of care with a trade-off between
beneficial and adverse effects (Enkin et al., 2000). Balloon
catheters (e.g., Foley catheter) can be inserted into the intracervical canal to ripen and dilate the cervix. Hydroscopic
dilators (substances that absorb fluid from surrounding tis-
sues and then enlarge) also can be used for cervical ripening. Laminaria tents (natural cervical dilators made from desiccated seaweed) and synthetic dilators containing magnesium sulfate (Lamicel) are inserted into the endocervix
without rupturing the membranes. As they absorb fluid, they
expand and cause cervical dilation. These dilators are left in
place for 6 to 12 hours before being removed to assess cervical dilation. Fresh dilators are inserted if further cervical
dilation is necessary. Synthetic dilators swell faster than
natural dilators and become larger with less discomfort
(Simpson, 2002). Amniotomy and membrane stripping also
can be used to ripen the cervix (Norwitz, Robinson, & Repke,
2002).
Amniotomy. Amniotomy (i.e., artificial rupture of
membranes [AROM]) can be used to induce labor when the
condition of the cervix is favorable (ripe) or to augment labor if progress begins to slow. Labor usually begins within
12 hours of the rupture. However, if amniotomy does not
stimulate labor, the resulting prolonged rupture may lead to
infection. Other potential risks include umbilical cord pro-
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24
Labor and Birth at Risk
793
Medication Guide
Cervical Ripening Using Prostaglandin
E2 (PGE2): Dinoprostone (Cervidil Insert;
Prepidil Gel)
NURSING CONSIDERATIONS
ACTION
•
•
•
PGE2 ripens the cervix, making it softer and causing it to
begin to dilate and efface; stimulates uterine contractions.
INDICATIONS
•
PGE2 is used for preinduction cervical ripening (ripening
of cervix before oxytocin induction of labor when the
Bishop score is 4 or less) and for inducement of labor or
abortion (abortifacient agent).
•
DOSAGE
Cervidil Insert:
• Dosage is 10 mg of dinoprostone designed to be released
gradually (approximately 0.3 mg /hr) over 12 hr. Insert is
placed transversely into the posterior fornix of vagina. The
insert is removed at the onset of active labor or after
12 hours.
Prepidil Gel:
• Dosage is 0.5 mg dinoprostone in 2.5-ml syringe. Gel is
administered through a catheter attached to the syringe
into the cervical canal just below internal cervical os.
Dose may be repeated every 6 hr as needed for cervical ripening up to a maximum of 1.5 mg in a 24-hr
period.
•
•
•
•
•
•
ADVERSE REACTIONS
•
Potential adverse reactions include headache, nausea
and vomiting, diarrhea, fever, hypotension, tachysystole (12 or more uterine contractions in 20 minutes
without alteration of fetal heart rate [FHR] pattern),
hyperstimulation of the uterus (tachysystole with nonreassuring FHR patterns), or fetal passage of meconium.
lapse and fetal injury. Once an amniotomy is performed, the
woman is committed to labor with an unknown outcome
for how and when she will give birth.
Before the procedure, the woman should be told what to
expect; she also should be assured that the actual rupture of
the membranes is painless for her and the fetus, although she
may experience some discomfort when the Amnihook or
other sharp instrument is inserted through the vagina and
cervix (Procedure box).
The presenting part of the fetus should be engaged and
well applied to the cervix to prevent cord prolapse. The
woman should be free of active infection of the genital tract
(e.g., herpes) and human immunodeficiency virus (HIV) infection (Norwitz, Robinson, & Repke, 2002). The membranes are ruptured with an Amnihook or other sharp instrument, and the amniotic fluid is allowed to drain slowly.
The color, odor, and consistency of the fluid is assessed (i.e.,
•
•
•
Explain procedure to woman and her family. Ensure that
an informed consent has been obtained as per agency
policy.
Assess maternal-fetal unit before each insertion and during treatment following agency protocol for frequency.
Assess maternal vital signs and health status, FHR pattern, and status of pregnancy, including indications for
cervical ripening or induction of labor, signs of labor or
impending labor, and the Bishop score. Recognize that a
nonreassuring FHR pattern; maternal fever, infection,
vaginal bleeding, or hypersensitivity; and regular, progressive uterine contractions contraindicate the use of
dinoprostone.
Use caution if the woman has a history of asthma; glaucoma; or renal, hepatic, or cardiovascular disorders.
Bring gel to room temperature before administration. Do
not force warming process by using a warm water bath
or other source of external heat (e.g., microwave).
Keep insert frozen until immediately before use; no need
to warm.
Have woman void before insertion.
Assist woman to maintain a supine position with lateral
tilt or a side-lying position for 15 to 30 min after insertion
of gel or for 2 hr after placement of insert.
Prepare to swab vagina to remove remaining gel using
a saline-soaked gauze, or pull string to remove insert and
to administer terbutaline 0.25 mg subcutaneously or intravenously if significant adverse reactions occur.
Initiate oxytocin for induction of labor within 6 to 12 hr
after last instillation of gel or within 30 min after removal
of the insert or follow agency protocol for induction if
ripening has occurred and labor has not begun.
Document all assessment findings and administration
procedures.
Not recommended for use if woman has had previous cesarean birth or if she has a uterine scar.
Dinoprostone is the only FDA-approved medication for
cervical ripening or labor induction.
for the presence or absence of meconium or blood). The
time of rupture is recorded.
NURSE ALERT The FHR is assessed before and immediately after the amniotomy to detect any changes (e.g.,
transient tachycardia is common, but bradycardia and
variable decelerations are not) that may indicate cord
compression or prolapse.
The woman’s temperature should be checked at least
every 2 hours to rule out possible infection. If her temperature is 38° C or higher, the primary health care provider
should be notified. The nurse assesses for other signs and
symptoms of infection, such as maternal chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia (Simpson, 2002). Comfort measures, such as
frequently changing the woman’s underpads and perineal
cleansing, are implemented.
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Procedure
Assisting with Amniotomy
PROCEDURE
•
•
•
•
•
•
•
•
•
•
Explain to the woman what will be done.
Assess FHR before procedure begins to obtain a baseline reading.
Place several underpads under the woman’s buttocks
to absorb the fluid.
Position the woman on a padded bed pan, fracture pan,
or rolled up towel to elevate her hips.
Assist the health care provider who is performing the
procedure by providing sterile gloves and lubricant for
the vaginal examination.
Unwrap sterile package containing Amnihook or Allis
clamp and pass instrument to the primary health care
provider, who inserts it alongside the fingers and then
hooks and tears the membranes.
Reassess the FHR.
Assess the color, consistency, and odor of the fluid.
Assess the woman’s temperature every 2 hours or per
protocol.
Evaluate the woman for signs and symptoms of infection.
DOCUMENTATION
•
Record the following:
Time of rupture
Color, odor, and consistency of the fluid
FHR before and after the procedure
Maternal status (how well procedure was tolerated)
Oxytocin. Oxytocin is a hormone normally produced
by the posterior pituitary gland; it stimulates uterine contractions. Synthetic oxytocin may be used either to induce
labor or to augment a labor that is progressing slowly because
of inadequate uterine contractions.
The indications for oxytocin induction or augmentation
of labor may include, but are not limited to, the following:
Suspected fetal jeopardy (e.g., IUGR)
Inadequate uterine contractions; dystocia
PROM
Postterm pregnancy
Chorioamnionitis
Maternal medical problems (e.g., woman with severe
Rh isoimmunization, inadequately controlled diabetes
mellitus, chronic renal disease, or chronic pulmonary
disease)
Severe preeclampsia
Fetal death
Multiparous women with a history of precipitous labor or who live far from the hospital
The management of stimulation of labor is the same regardless of the indication. Because of the potential dangers
associated with the injection of oxytocin in the prenatal and
intrapartal periods, the FDA has issued certain restrictions
to its use.
Contraindications to oxytocin stimulation of labor include, but are not limited to, the following:
CPD, prolapsed cord, transverse lie
•
•
•
•
•
•
fetal status
• Nonreassuring
Placenta
previa
or vasa previa
• Prior classic uterine
or uterine surgery
• Active genital herpesincision
infection
•Certain maternal and fetal conditions, although not contraindications to the use of oxytocin to stimulate labor, do
require special caution during its administration. These conditions include the following:
Multifetal presentation
Breech presentation
Presenting part above the pelvic inlet
Abnormal fetal heart pattern not requiring emergency
birth
Polyhydramnios
Grand multiparity
Maternal cardiac disease; hypertension
Oxytocin use can present hazards to the mother and fetus. These hazards are primarily dose related, with most problems caused by high doses that are given rapidly. Maternal
hazards include water intoxication and tumultuous labor
with tetanic contractions, which may cause premature separation of the placenta, rupture of the uterus, lacerations of
the cervix, or postpartum hemorrhage. These complications
can lead to infection, disseminated intravascular coagulation,
or amniotic fluid embolism. Women may become anxious
or fearful if the induction is not successful because they may
then have concerns about the method of birth.
Uterine hyperstimulation reduces the blood flow through
the placenta and results in FHR decelerations (bradycardia,
diminished variability, late decelerations), fetal asphyxia, and
neonatal hypoxia. If the estimated date of birth is inaccurate,
physical injury, neonatal hyperbilirubinemia, and prematurity are other hazards.
The primary health care provider orders induction or
augmentation of labor with oxytocin. The nurse implements
the order by initiating the primary intravenous infusion and
administering the oxytocin solution through a secondary
line. The nurse’s actions related to assessment and care of
a woman whose labor is being induced are guided by hos-
•
•
•
•
•
•
•
•
•
•
•
Fig. 24-7 Woman in side-lying position receiving oxytocin.
(Courtesy Michael S. Clement, MD, Mesa, AZ.)
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pital protocol and professional standards (Fig. 24-7; Box
24-8).
A commonly recommended initial dosage is 0.5 to 1
milliunits/min with increments of 1 or 2 milliunits/min every
30 to 60 minutes because 30 to 40 minutes is required for a
steady state of oxytocin to be reached and for the full effect
of a dosage increment to be reflected in more intense, frequent, and longer contractions (Simpson & Atterbury, 2003).
Such an approach reduces the amount of oxytocin required
to achieve a spontaneous vaginal birth and decreases the risk
for uterine hyperstimulation, dysfunctional labor, fetal distress, and other adverse reactions such as water intoxication
(Norwitz, Robinson, & Repke, 2002; Simpson, 2002).
24
Labor and Birth at Risk
795
Nursing considerations. An evidence-based written
protocol for the preparation and administration of oxytocin
should be established by the obstetric department (physicians, nurses) in each institution (see Box 24-8).
NURSE ALERT Oxytocin is discontinued immediately
and the primary health care provider notified if uterine
hyperstimulation, nonreassuring FHR and pattern, or
both occur.
Other nursing interventions, such as administering
oxygen by face mask, positioning the woman on her side,
and infusing more intravenous fluids are implemented
immediately (Emergency box). Based on the status of the
BOX 24-8
Protocol: Induction of Labor with Oxytocin
PATIENT AND FAMILY TEACHING
MATERNAL AND FETAL ASSESSMENTS
Explain technique, rationale, and reactions to expect:
• Route and rate for administration of medication
• What “piggyback” (Secondary intravenous line inserted
into primary intravenous line) is for
• Reasons for use:
—Induce labor, improve labor
• Reactions to expect concerning the nature of contractions:
the intensity of contraction increases more rapidly, holds
the peak longer, and ends more quickly; contractions will
come regularly and more often
• Monitoring to anticipate:
—Maternal: blood pressure, pulse, uterine contractions,
uterine tone
—Fetal: heart rate, activity
• Success to expect: a favorable outcome will depend on
inducibility of the cervix (e.g., Bishop score of 9 for a primipara)
• Keep woman and support person informed of progress
•
ADMINISTRATION
EMERGENCY MEASURES
Position woman in side-lying or upright position
Assess status of maternal fetal unit
Prepare solutions and administer with pump delivery
system according to prescribed orders:
• Infusion pump and solution are set up (e.g., 10 units/
1000 ml isotonic electrolyte solution)
• Piggyback solution is connected to IV line at proximal port
(port nearest point of venous insertion)
• Solution with oxytocin is flagged with a medication label
• Begin induction at 0.5 to 2 milliunits/min
• Increase dose 1 to 2 milliunits/min at intervals of 15 to 60
minutes until a dose of up to 20 to 40 milliunits/min is
reached
Discontinue use of oxytocin per hospital protocol:
• Turn woman on her side
• Increase primary IV rate up to 200 ml/hr, unless patient
has water intoxication, in which case, the rate is decreased to one that keeps the vein open
• Give woman oxygen by face mask at 8 to 10 L/min or per
protocol or physician’s or nurse-midwife’s order
•
•
•
•
•
•
REPORTABLE CONDITIONS
•
•
•
•
•
•
•
Intensity of contractions results in intrauterine pressures
of 40 to 90 mm Hg (shown by internal monitor)
Duration of contractions is 40 to 90 seconds
Frequency of contractions is 2- to 3-minute intervals
Cervical dilation of 1 cm/hr occurs in the active phase
Uterine hyperstimulation
Nonreassuring FHR pattern
Suspected uterine rupture
Inadequate uterine response at 20 milliunits/min
DOCUMENTATION
•
•
MAINTAIN DOSE IF
•
Monitor blood pressure, pulse, and respirations every
30 to 60 minutes and with every increment in dose
Monitor contraction pattern and uterine resting tone
every 15 minutes and with every increment in dose
Assess intake and output; limit IV intake to 1000 ml/8 hr;
output should be 120 ml or more every 4 hours
Perform vaginal examination as indicated
Monitor for nausea, vomiting, headache, hypotension
Assess fetal status using electronic fetal monitoring; evaluate tracing every 15 minutes and with every increment
in dose
Observe emotional responses of woman and her partner
•
Medication: kind, amount, time of beginning, increasing
dose, maintaining dose, and discontinuing medication in
patient record and on monitor strip
Reactions of mother and fetus
—Pattern of labor
—Progress of labor
—FHR and pattern
—Maternal vital signs
—Nursing interventions and woman’s response
Notification of physician or nurse-midwife
From Ruchata, P., Metheby, N., Essenpreis, H., & Borcherding, K. (2002). Current practices in oxytocin dilution and fluid administration for induction of labor. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31(5), 545-550; Simpson, K. (2002). Cervical ripening and induction and augmentation of labor (2nd ed.). Washington, DC: AWHONN.
FHR, Fetal heart rate; IV, intravenous.
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EMERGENCY
Uterine Hyperstimulation with
Oxytocin
SIGNS
•
•
•
Uterine contractions lasting more than 90 seconds and
occurring more frequently than every 2 minutes
Uterine resting tone greater than 20 mm Hg
Nonreassuring FHR:
—Abnormal baseline (110 or 160 beats/min)
—Absent variability
—Repeated late decelerations or prolonged decelerations
INTERVENTIONS
•
•
•
•
•
•
•
Maintain woman in side-lying position.
Turn off oxytocin infusion; keep maintenance IV line
open; increase rate.
Start administering oxygen by face mask, per protocol
or physician’s order.
Notify primary health care provider.
Prepare to administer terbutaline (Brethine) 0.25 mg
subcutaneously if ordered to decrease uterine activity.
Continue monitoring FHR and uterine activity.
Document responses to actions.
FHR, Fetal heart rate; IV, intravenous.
maternal-fetal unit, the primary health care provider may order that the infusion be restarted once the FHR and uterine activity return to acceptable levels. Depending on the
length of time the infusion was discontinued, the induction
may be restarted at half the rate that resulted in hyperstimulation (e.g., discontinued for 10 to 20 minutes) or at the
same rate as the initial rate (e.g., discontinued for more than
30 to 40 minutes) (Simpson, 2002) (Plan of Care: Dysfunctional Labor).
Augmentation of labor
Augmentation of labor is the stimulation of uterine contractions after labor has started spontaneously but progress
is unsatisfactory. Augmentation is usually implemented for
the management of hypotonic uterine dysfunction, resulting in a slowing of the labor process (protracted active phase).
Common augmentation methods include oxytocin infusion,
amniotomy, and nipple stimulation. Noninvasive methods
such as emptying the bladder, ambulation and position
changes, relaxation measures, nourishment and hydration,
and hydrotherapy should be attempted before invasive interventions are initiated. The administration procedure and
nursing assessment and care measures for augmentation of
labor with oxytocin are similar to those used for induction
of labor with oxytocin; protocols for dosage and frequency
of increments may vary (e.g., lower dosages may be needed
to achieve spontaneous vaginal birth (Gilbert & Harmon,
2003; Simpson, 2002).
Some physicians advocate active management of labor, that
is, the augmentation of labor to establish efficient labor with
the aggressive use of oxytocin so that the woman gives birth
within 12 hours of admission to the labor unit. Advocates
of active management believe that intervening early (as soon
as a nulliparous labor is not progressing at least 1 cm/hr) with
use of higher pharmacologic oxytocin doses administered at
frequent increment intervals (e.g., a starting dose of 6 milliunits/min with increases of 6 milliunits/min every 15 minutes to a maximum dose of 40 milliunits/min) shortens labor and is associated with a lower incidence of cesarean birth
(Norwitz, Robinson, & Repke, 2002; Simpson, 2002).
Additional components of the active management of labor include strict criteria to diagnose that the woman is in
active labor with 100% effacement, amniotomy within
1 hour of admission of a woman in labor if spontaneous rupture of the membranes has not occurred, and continuous
presence of a personal nurse who provides one-on-one care
for the woman while she is in labor. When all components
are fully implemented, active management of labor is associated with a lower incidence of cesarean birth. Active management of labor continues to be under study in the United
States to determine effectiveness and impact on perinatal
morbidity and mortality. Thus far, results have been disappointing, especially in terms of reducing the rate of cesarean
births. The disappointing results have been attributed in part
to a greater than one-to-one nurse-patient ratio and the high
rate of epidural anesthesia. It is considered to be a form of
care of unknown effectiveness (Enkin et al., 2000; Gilbert &
Harmon, 2003).
Forceps-assisted birth
A forceps-assisted birth is one in which an instrument
with two curved blades is used to assist in the birth of the
fetal head. The cephalic-like curve of the forceps commonly
used is similar to the shape of the fetal head, with a pelvic
curve to the blades conforming to the curve of the pelvic
axis. The blades are joined by a pin, screw, or groove arrangement. These locks prevent the forceps from compressing the
fetal skull. Maternal indications for forceps-assisted birth include the need to shorten the second stage of labor in the
event of dystocia or to compensate for the woman’s deficient
expulsive efforts (e.g., if she is tired or has been given spinal
or epidural anesthesia), or to reverse a dangerous condition
(e.g., cardiac decompensation).
Fetal indications include birth of a fetus in distress or in
certain abnormal presentations; arrest of rotation; or delivery of the head in a breech presentation. The use of forceps
during childbirth has been decreasing. In 2002, forceps or vacuum were used to assist 5.9% of births (Martin et al., 2003).
Certain conditions are required for a forceps-assisted birth
to be successful. The woman’s cervix must be fully dilated
to avert lacerations and hemorrhage. The bladder should be
empty. The presenting part must be engaged, and a vertex
presentation is desired. Membranes must be ruptured so that
the position of the fetal head can be determined and the forceps can firmly grasp the head during birth (Fig. 24-8). In addition, CPD should not be present.
Nursing considerations. When a forcepsassisted birth is deemed necessary, the nurse obtains the type
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PLAN OF CARE
Nursing Interventions/Rationales
•
•
•
•
•
•
•
•
•
•
Labor and Birth at Risk
797
Dysfunctional Labor: Hypotonic Uterine Dysfunction
with Protracted Active Phase
NURSING DIAGNOSIS Risk for injury to mother
and/or fetus related to oxytocin augmentation
secondary to dysfunctional labor
Expected Outcomes Maternal-fetal well-being is
maintained; labor progresses and birth occurs.
•
24
Explain oxytocin protocol to woman and her labor partner to
allay apprehension and enhance participation.
Encourage woman to void before beginning protocol to prevent discomfort and remove a barrier to labor progress.
Apply the electronic fetal monitor per hospital protocol and
obtain a 15- to 20-min baseline strip to ensure adequate assessment of FHR and contractions.
Position woman in a side-lying position and administer the
oxytocin per physician order using an IV infusion pump to
stimulate uterine activity and provide adequate control of the
flow rate.
Regulate the oxytocin per protocol (e.g., advancing the dose
in increments of 1 to 2 milliunits/min every 30 to 60 min) to
allow adequate evaluation of the woman’s response to stimulation and to prevent hyperstimulation and fetal hypoxia.
Maintain oxytocin dose and rate when contractions occur
every 2 to 3 min with a duration of 40 to 90 sec and intrauterine pressures of 60 to 90 mm Hg (if internal monitoring is used) to produce effective uterine stimulation without
risk of hyperstimulation.
Monitor maternal vital signs every 30 to 60 min to assess for
oxytocin-induced hypertension.
Monitor contractility pattern and FHR and pattern every
15 min to assess uterine activity for possible hypertonicity or
ineffective uterine response to oxytocin and to detect evidence of fetal distress.
Monitor intake, output, and specific gravity (limit intake to
1000 ml/8 hr; output should be at least 120 ml/4 hr) to assess
for urinary retention and prevent water intoxication.
Monitor cervical dilation, effacement, and station to assess
progress of labor.
If hypertonicity or signs of fetal distress are detected, discontinue oxytocin immediately to arrest the progress of hypertonicity; turn woman on her side to increase placental
blood flow; increase primary IV rate to 200 ml/hr (unless signs
of water toxicity are present); administer oxygen via face
mask to enhance placental perfusion; notify primary health
care provider; and continuously monitor maternal vital signs
and FHR to provide ongoing assessment of maternal and fetal status.
•
Maintain Standard Precautions and use scrupulous handwashing techniques when providing care to prevent the
spread of infection.
NURSING DIAGNOSIS Acute pain related to increasing frequency, regularity, intensity, and prolonged peak of contractions
Expected Outcome The woman exhibits signs of
decreased discomfort.
Nursing Interventions/Rationales
•
•
•
•
•
Prepare woman and labor partner for the change in the nature of the contractions once the oxytocin drip is initiated to
prepare them and allow for more effective coping.
Review the use of specific techniques such as conscious relaxation, focused breathing, effleurage, massage, and application of sacral pressure to increase relaxation, decrease
intensity of pain of contractions, and promote use of controlled thought and direction of energy.
Provide comfort measures such as frequent mouth care to
prevent dry mouth, application of damp cloth to forehead and
changing of damp gown or bed covers to relieve discomfort
of diaphoresis, and changing of position to reduce stiffness.
Encourage conscious relaxation between contractions to prevent fatigue, which contributes to increased pain perceptions.
Remind woman and labor partner that analgesics are available for use during labor to provide knowledge to help them
make decisions about pain control.
NURSING DIAGNOSIS Anxiety related to prolonged labor, increased pain, and fatigue
Expected Outcomes Woman’s anxiety is reduced;
woman actively participates in the labor process.
Nursing Interventions/Rationales
•
•
•
•
Provide ongoing feedback to woman and partner to allay anxiety and enhance participation.
Present care options when possible to increase feelings of
control.
Continue to provide comfort measures to maintain a posture
of support and caring and to aid woman in focusing on the
labor process.
Encourage woman and partner to continue to use those
mechanisms that promote effective labor (e.g., breathing, activity, positioning) to keep woman and partner actively involved in process.
FHR, Fetal heart rate; IV, intravenous.
of forceps requested by the primary health care provider. The
nurse may explain to the mother that the forceps blades fit
like two tablespoons around an egg, with the blades placed
in front of the baby’s ears. The nurse usually coaches the
woman not to push during contractions unless the primary
health care provider instructs the woman to push as traction
is being applied during contractions.
NURSE ALERT Because compression of the cord between the fetal head and the forceps will cause a decrease in FHR, the FHR and pattern are assessed, re-
ported, and recorded before and after application of the
forceps.
If a decrease in FHR occurs, the primary health care
provider removes and reapplies the forceps. After birth the
mother is assessed for vaginal and cervical lacerations (e.g.,
bleeding that occurs even with a contracted uterus); urine
retention, which may result from bladder or urethral injuries;
and hematoma formation in the pelvic soft tissues, which
may result from blood vessel damage. The infant should be
assessed for bruising or abrasions at the site of the blade applications, facial palsy resulting from pressure of the blades
CD: Plan of Care—Dysfunctional Labor
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COMPLICATIONS OF CHILDBEARING
Outlet forceps-assisted extraction of the head.
on the facial nerve (cranial nerve VII), and subdural
hematoma. Newborn and postpartum caregivers should be
told that a forceps-assisted birth was performed.
Vacuum-assisted Birth
Vacuum-assisted birth, or vacuum extraction, is a birth
method involving the attachment of a vacuum cup to the
fetal head, using negative pressure to assist in the birth of
the head. Indications and prerequisites for its use are similar to those for outlet forceps. It is usually not used to assist birth before 34 weeks of gestation (Cunningham et al.,
2005). When an operative vaginal birth is required, vacuum
assistance is preferred as a beneficial form of care when compared with forceps assistance (Enkin et al., 2000).
When the birth is to be vacuum assisted, the woman is
prepared for a vaginal birth in the lithotomy position to allow sufficient traction. The cup is applied to the fetal head,
and a caput develops inside the cup as the pressure is initiated (Fig. 24-9). Traction is applied to facilitate descent of
the fetal head, and the woman is encouraged to push as suction is applied. As the head crowns, an episiotomy is performed if necessary. The vacuum cup is released and re-
moved after birth of the head. If vacuum extraction is not
successful, a or cesarean birth is usually performed.
Risks to the newborn include cephalhematoma, scalp lacerations, and subdural hematoma. Fetal complications can
be reduced by strict adherence to the manufacturer’s recommendations for method of application, degree of suction,
and duration of application. Maternal complications are uncommon but can include perineal, vaginal, or cervical lacerations and soft-tissue hematomas.
Nursing considerations. The nurse’s role for the
woman who has a vacuum-assisted birth is one of support
person and educator. The nurse can prepare the woman for
birth and encourage her to remain active in the birth process
by pushing during contractions. The FHR should be assessed frequently during the procedure. After birth, the newborn should be observed for signs of trauma and infection
at the application site and for cerebral irritation (e.g., poor
sucking or listlessness). The newborn may be at risk for
neonatal jaundice as bruising resolves. The parents may need
to be reassured that the caput succedaneum will begin to disappear in a few hours. Neonatal caregivers should be told
that the birth was vacuum assisted.
Cesarean birth
Cesarean birth is the birth of a fetus through a transabdominal incision in the uterus. Whether cesarean birth is
planned (scheduled) or unplanned (emergency), the loss of
the experience of giving birth to a child in the traditional
manner may have a negative effect on a woman’s selfconcept. An effort is therefore made to maintain the focus
on the birth of a child rather than on the operative procedure.
The purpose of cesarean birth is to preserve the life or
health of the mother and her fetus; it may be the best choice
for birth when there is evidence of maternal or fetal complications. Since the advent of modern surgical methods and
care and the use of antibiotics, maternal and fetal morbidity and mortality have decreased. In addition, incisions are
made in the lower uterine segment rather than in the muscular body of the uterus and thus more effective healing
A
B
Fig. 24-9 Use of vacuum extraction to rotate fetal head and assist with descent. A, Arrow indicates direction of traction on the vacuum cup. B, Caput succedaneum formed by the vacuum cup.
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is promoted. However, despite these advances, cesarean birth
still poses threats to the health of the mother and infant.
The incidence of cesarean births increased to 27.6% in
2003, the highest rate ever reported in the United States, with
the primary cesarean birth rate at 19.1% (Hamilton et al.,
2004). In Canada the rate was 22.1% in 2001 (Liu et al.,
2004). Factors cited in this increase include use of electronic
fetal monitoring and epidural anesthesia; an increase in the
number of first-time pregnancies, as well as the number of
pregnancies at an older age; and the decline in the rate of
vaginal birth after cesarean (VBAC) (10.6% in 2003 in the
United States; 28.5% in 2001 in Canada) (Hamilton et al.,
2004; Liu et al., 2004). Women 35 to 39 years of age have
a cesarean birth rate of 35%, and those 40 to 54 years of age
have a rate of 40.7%, over twice the rate for teenage women
(18%) (Martin et al., 2003).
Women who have private insurance, who are of a higher
socioeconomic status, or who give birth in a private hospital are more likely to experience cesarean birth than are
women who are poor, who have no insurance, who are receiving public assistance (e.g., Medicaid), or who give birth
in a public hospital (Gilbert & Harmon, 2003; Moore, 2003).
Approaches for the management of labor and birth to reduce the rate of cesarean births while increasing the rate of
VBAC are presented in Box 24-9. However, the rate of
24
Labor and Birth at Risk
799
VBAC is decreasing. This decline may be a result of reports
of risks of VBAC, legal pressures, conservative practice guidelines, and debate regarding the relative benefits and risks of
the cesarean versus the vaginal route for births (Martin et al.,
2003).
The type of nursing care given also may influence the rate
of cesarean births. A labor management approach that uses
one-to-one support and emphasizes ambulation, maternal
position changes, relaxation measures, oral fluids and nutrition, hydrotherapy, and nonpharmacologic pain relief
facilitates the progress of labor and reduces the incidence
of dystocia (AWHONN, 2000; Hodnett, 2002; Miltner,
2002).
The labor management approach that most consistently
reduced cesarean birth rates was one-to-one support of the
laboring woman by another woman such as a nurse, nursemidwife, or doula (Hodnett, Gates, Hofmeyr, & Sakala,
2003; Hodnett et al., 2002).
Indications. Few absolute indications exist for cesarean birth. Today most are performed primarily for the
benefit of the fetus. The most common indications for cesarean birth are related to labor and birth complications. The
complications most closely associated with cesarean birth include CPD, malpresentations such as breech and shoulder,
placental abnormalities (e.g., previa, abruptio), dysfunctional
BOX 24-9
Selected Measures to Reduce Cesarean Birth Rate and Increase Rate of Vaginal Birth
after Cesarean
EDUCATE WOMEN REGARDING
INITIATE A DOULA PROGRAM THAT
•
•
•
•
•
•
Advantages and safety of the home environment for early
or latent labor
Indicators for hospital admission
Management techniques to use during labor to enhance
progress
Nonpharmacologic measures to reduce pain and discomfort and enhance relaxation
Safety and effectiveness of TOL and VBAC
ESTABLISH ADMISSION CRITERIA FOR WOMEN
IN LABOR
•
•
•
•
Distinguish clinical manifestations for false labor, latent
or early labor, and active labor
Conduct admission assessments in a separate admissions area
Send women in false or early or latent labor home or keep
them in the admissions area
Admit women in active labor to the labor and birth unit
DEVELOP A PHILOSOPHY OF LABOR
MANAGEMENT THAT
•
•
•
•
•
•
USE APPROPRIATE ASSESSMENT
TECHNIQUES TO
•
•
Determine status of the maternal-fetal unit
Establish an individualized rationale for initiating labor interventions such as epidural anesthesia, induction or augmentation, amniotomy, cesarean birth
TOL, Trial of labor; VBAC, vaginal birth after cesarean.
Provides one-to-one support for women in labor
•
•
•
Schedules admission during active labor
Avoids automatic interventions such as routine induction
for spontaneous rupture of membranes at term or postterm pregnancy and cesarean birth for breech presentation, twin gestation, genital herpes, or failure to progress
Relies on assessment findings reflective of the status of
the maternal-fetal unit rather than strict adherence to set
ranges for the duration of the stages and phases of labor
Employs intermittent rather than continuous electronic fetal monitoring of low risk pregnant women
Focuses on measures that are known to enhance the
progress of labor such as upright positions, frequent position changes, ambulation, oral nutrition and hydration,
relaxation techniques, hydrotherapy
Emphasizes nonpharmacologic measures to relieve
pain
Uses nonpharmacologic measures in a manner that reduces their labor-inhibiting effects
Establishes criteria for elective cesarean birth and TOL
Encourages women who have had a previous cesarean
birth to participate in TOL to attempt a vaginal birth
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labor pattern, umbilical cord prolapse, fetal distress, and multiple gestation (see Evidence-Based Practice Box) on p. 787.
Medical risk factors most closely associated with cesarean
birth include hypertensive disorders, active genital herpes,
positive HIV status, and diabetes (Martin et al., 2003).
Elective cesarean birth. Women are requesting
cesarean births for reasons other than medical, obstetric, or
fetal indications. These reasons include the belief that the
surgery will prevent future problems with pelvic support or
sexual dysfunction and the convenience of planning a date
or having control and choice about when to give birth
(Williams, 2005). Some multiparous women may request a
cesarean after a previous traumatic vaginal birth or psychologic trauma (Gardner, 2003). In a committee opinion
ACOG notes that the right of patients to refuse surgery is
well known (ACOG, 2003). It is less clear if they have the
right to ask for surgery. The Society of Obstetricians and Gynaecologists of Canada (SOGC) promotes natural childbirth,
does not promote elective cesarean birth but believes that
the final decision as to the safest route for childbirth rests
with the woman and her health care provider (SOGC, 2004).
It is essential that women are fully informed about the risks
and benefits of cesarean birth when they consider the request
for elective cesarean (McFarlin, 2004).
Forced cesarean birth. A woman’s refusal to undergo cesarean birth when indicated for fetal reasons is often described as a maternal-fetal conflict. Health care
providers are ethically obliged to protect the well-being of
both the mother and the fetus; a decision for one affects the
other. If a woman refuses a cesarean birth that is recommended because of fetal jeopardy, health care providers must
make every effort to find out why she is refusing and provide information that may persuade her to change her mind.
If the woman continues to refuse surgery, then health care
providers must decide if it is ethical to get a court order for
the surgery; however, every effort should be made to avoid
this legal step.
Surgical techniques. The two main types of cesarean operation are the classic and the lower-segment cesarean incisions. Classic cesarean birth is rarely performed
today, although it may be used when rapid birth is necessary and in some cases of shoulder presentation and placenta
previa. The incision is made vertically into the upper body
of the uterus (Fig. 24-10, A). Because the procedure is associated with a higher incidence of blood loss, infection, and
uterine rupture in subsequent pregnancies than is lowersegment cesarean birth, vaginal birth after a classic cesarean
birth is contraindicated.
Lower-segment cesarean birth can be achieved through
a vertical or transverse incision into the uterus (Fig. 24-10,
B and C). The transverse incision is more popular, however,
because it is easier to perform, is associated with less blood
loss and fewer postoperative infections, and is less likely to
rupture in subsequent pregnancies (Bowes & Thorp, 2004).
Complications and risks. Maternal complications of cesarean births include aspiration, pulmonary
SKIN INCISION
UTERINE INCISION
Vertical
through skin
A
Vertical
through uterus
Horizontal through
skin (first skin crease
under hairline)
B
Vertical through
lower uterine
segment
Horizontal through
skin (first skin crease
under hairline)
C
Horizontal through
uterus (lower
uterine segment)
Fig. 24-10 Cesarean birth; skin and uterine incisions.
A, Classic: vertical incisions of skin and uterus. B, Low cervical: horizontal incision of skin; vertical incision of uterus.
C, Low cervical: horizontal incisions of skin and uterus.
embolism, wound infection, wound dehiscence, thrombophlebitis, hemorrhage, urinary tract infection, injuries to
the bladder or bowel, and complications related to anesthesia. The fetus may be born prematurely if the gestational
age has not been accurately determined; fetal injuries can
occur during the surgery (Bowes & Thorp, 2004). Besides
these risks, the woman is at economic risk because the cost
of cesarean birth is higher than that of vaginal birth, and
a longer recovery period may require additional expenditures.
Many women who have a cesarean birth speak of having
feelings that interfere with their maintaining an adequate selfconcept. These feelings include fear, disappointment, frustration at losing control, anger (the “why me” syndrome),
and loss of self-esteem related to a change in body image and
perceived inability to give birth as they had expected and
hoped. Often women experience a delay in their ability to
interact with their newborns after birth. These women are
less likely to breastfeed and may even have some difficulty
expressing positive feelings about their newborns for some
time after birth. They are often less satisfied with their childbirth experience and report more fatigue and poor physical
functioning during the first few weeks after discharge. Success at mothering and in the recovery process can do much
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to restore the self-esteem of these women. Some women see
the scar as mutilating, and worries concerning sexual attractiveness may surface. Some men are fearful of resuming
intercourse because of the fear of hurting their partners. Parents may wonder if a cesarean birth was absolutely necessary,
and such feelings may surface even years later. They should
therefore be given opportunities to discuss the experience
to try to understand and resolve concerns after the birth.
Anesthesia. Spinal, epidural, and general anesthetics are used for cesarean births. Epidural blocks are popular
because women want to be awake for and aware of the birth
experience. However, the choice of anesthetic depends on
several factors. The mother’s medical history or present condition, such as a spinal injury, hemorrhage, or coagulopathy,
may rule out the use of regional anesthesia. Time is another
factor, especially if there is an emergency and the life of the
mother or infant is at stake. In such a case, general anesthesia
will most likely be used unless the woman already has an
epidural block in effect. The woman herself is a factor. Either she may not know all the options or may have fears
about having “a needle in her back” or about being awake
and feeling pain. She needs to be fully informed about the
risks and benefits of the different types of anesthesia so that
she can participate in the decision whenever there is a choice.
Scheduled cesarean birth. Cesarean birth is
scheduled or planned if labor and vaginal birth are contraindicated (e.g., complete placenta previa, active genital
herpes, positive HIV status), if birth is necessary but labor
is not inducible (e.g., hypertensive states that cause a poor
intrauterine environment that threatens the fetus), or if this
has been decided on by the primary health care provider and
the woman (e.g., a repeat cesarean birth).
Women who are scheduled to have a cesarean birth have
time to prepare for it psychologically. However, the psychologic responses of these women may differ. Those having a repeat cesarean birth may have disturbing memories
of the conditions preceding the initial surgical birth (primary
cesarean birth) and of their experiences in the postoperative
recovery period. They may be concerned about the added
burdens of caring for an infant and perhaps other children
while recovering from a surgical operation. Others may feel
glad that they have been relieved of the uncertainty about
the date and time of the birth and are free of the pain of
labor.
Unplanned cesarean Birth. The psychosocial
outcomes of unplanned or emergency cesarean birth are
usually more pronounced and negative when compared with
the outcomes associated with a scheduled or planned cesarean birth. Women and their families experience abrupt
changes in their expectations for birth, postbirth care, and
the care of the new baby at home. This may be an extremely
traumatic experience for all.
The woman usually approaches the procedure tired and
discouraged after an ineffective and difficult labor. Fear predominates as she worries about her own safety and wellbeing and that of her fetus. She may be dehydrated, with low
24
Labor and Birth at Risk
801
glycogen reserves. Because preoperative procedures must be
done quickly and competently, the time for explanation of
the procedures and operation is often short. Because maternal and family anxiety levels are high at this time, much
of what is said may be forgotten or misunderstood. The
woman may experience feelings of anger or guilt in the postpartum period. Fatigue is often noticeable in these women,
and they need much supportive care.
After surgery, counseling strategies that have been implemented by nurses include providing women with opportunities to talk about their birth experience, express their
feelings about what happened, have their questions answered, address gaps in knowledge or understanding of
events, connect the event with emotions and behavior, and
talk about future pregnancies. More research is needed to determine how effective these strategies are for these women
in influencing their views about the unplanned cesarean
birth experience or about future pregnancies (Gamble &
Creedy, 2004).
Prenatal preparation. Concerned professional and
lay groups in the community have established councils for
cesarean birth to meet the needs of these women and their
families. Such groups advocate that a discussion of cesarean
birth be included in all parenthood preparation classes. No
woman can be guaranteed a vaginal birth, even if she is in
good health and there is no indication of danger to the fetus before the onset of labor. For this reason, every woman
needs to be aware of and prepared for this eventuality.
Childbirth educators stress the importance of emphasizing the similarities and differences between a cesarean and
a vaginal birth. In support of the philosophy of familycentered birth, many hospitals have instituted policies that
permit fathers and other partners and family members to
share in these births as they do in vaginal ones. Women who
have undergone cesarean birth agree that the continued presence and support of their partners helped them respond positively to the entire experience. In addition to preparing
women for the possibility of cesarean birth, childbirth educators should empower women to believe in their ability
to give birth vaginally and to seek care measures during labor that will enhance the progress of their labors and reduce
their risk for cesarean birth.
Preoperative care. Family-centered care is the goal
for the woman who is to undergo cesarean birth and for her
family. The preparation of the woman for cesarean birth is
the same as that done for other elective or emergency surgery. The primary health care provider discusses, with the
woman and her family, the need for the cesarean birth and
the prognosis for the mother and infant. The anesthesiologist assesses the woman’s cardiopulmonary system and describes the options for anesthesia. Informed consent is obtained for the procedure (Guidelines/Guías: Cesarean Birth).
Blood and urine tests are usually done a day or two before
a planned cesarean birth or on admission to the labor and
birth unit. Laboratory tests, most commonly ordered to establish baseline data, include a complete blood cell count and
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COMPLICATIONS OF CHILDBEARING
GUIDELINES/GUÍAS
Cesarean Birth—Informed Consent
•
•
•
•
You need a cesarean.
Necesita una operación cesárea.
Has your doctor discussed with you the reason for
needing a cesarean?
¿Ha hablado el doctor con usted sobre la necesidad de
tener una operación cesárea?
•
•
Do you understand why you need a cesarean?
¿Entiende usted por qué necesita una operación
cesárea?
•
Your signature on this form will allow us to proceed
with the surgery.
Su firma en este formulario nos permitirá seguir adelante con la operación.
•
•
•
A
Please sign this consent form.
Por favor, firme este formulario de autorización.
chemistry, blood typing and crossmatching, and urinalysis.
Maternal vital signs and blood pressure and FHR and pattern continue to be assessed per the hospital routine until
the operation begins. Physical preoperative preparation usually includes inserting a retention catheter to keep the bladder empty and administering prescribed preoperative medications. An abdominal-mons shave or a clipping of pubic
hair may be ordered by the primary health care provider. In
the event that general anesthesia will be used, an antacid, administered orally to neutralize gastric secretions in case of
aspiration, is a beneficial form of care (Enkin et al., 2000).
Intravenous fluids are started to maintain hydration and to
provide an open line for the administration of blood or medications if needed.
Removal of dentures, nail polish, and jewelry may be optional, depending on hospital policies and type of anesthesia used. If the woman wears glasses and is going to be awake,
the nurse should make sure her glasses accompany her to the
operating room so she can see her infant. If the woman wears
contact lenses, the nurse can find out whether they can be
worn for the birth.
During the preoperative preparation, the support person
is encouraged to remain with the woman as much as possible to provide continuing emotional support (if this action
is culturally acceptable to the woman and support person).
The nurse provides essential information about the preoperative procedures during this time. Although the nursing
actions may be carried out quickly if a cesarean birth is unplanned, verbal communication, particularly explanation, is
important. Silence can be frightening to the woman and her
support person. The nurse’s use of touch can communicate
feelings of care and concern for the woman. The nurse can
assess the woman’s and her partner’s perceptions about cesarean birth (e.g., the woman feels that she is a failure because she did not have a vaginal birth). As the woman expresses her feelings, the nurse may identify a potential for
B
C
Fig. 24-11 Cesarean birth. A, “Bikini” incision has been
made, the muscle layer is separated, the abdomen is entered,
and the uterus has been exposed and incised; suctioning of
amniotic fluid continues as head is brought up through the incision. Note small amount of bleeding. B,The neonate’s birth
through the uterine incision is nearly complete. C, A quick assessment is performed; note extreme molding of head resulting from cephalopelvic disproportion. (Courtesy Marjorie
Pyle, RNC, Lifecircle, Costa Mesa, CA.)
a disturbance in self-concept during the postpartum period
that may need to be addressed. If there is time before the
birth, the nurse can teach the woman about postoperative
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expectations and about pain relief, turning, coughing, and
deep-breathing measures.
Intraoperative care. Cesarean births occur in operating rooms in the surgical suite or in the labor and birth
unit. Once the woman has been taken to the operating
room, her care becomes the responsibility of the obstetric
team, surgeon, anesthesiologist, pediatrician, and surgical
nursing staff (Fig. 24-11). If possible, the partner, who is
dressed appropriately for the operating room, accompanies
the mother to the operating room and remains close to her
so that continued support and comfort can be provided.
The nurse who is circulating may assist with positioning
the woman on the birth (surgical) table. It is important to
position her so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is usually accomplished by
placing a wedge under the hip. A Foley catheter is inserted
into the bladder at this time if one is not already in place.
If the partner is not allowed or chooses not to be present,
the nurse can stay in communication with him or her and
give progress reports whenever possible. If the woman is
awake during the birth, the nurse, anesthesiologist, or both
can tell her what is happening and provide support. She may
be anxious about the sensations she is experiencing, such as
the coldness of solutions used to prepare the abdomen and
pressure or pulling during the actual birth of the infant. She
also may be apprehensive because of the bright lights or the
presence of unfamiliar equipment and masked and gowned
personnel in the room. Explanations by the nurse can help
to decrease the woman’s anxiety.
Care of the infant usually is delegated to a pediatrician
or a nurse team skilled in neonatal resuscitation, because
these infants are considered to be at risk until there is evidence of physiologic stability after the birth.
24
Labor and Birth at Risk
803
A crib with resuscitation equipment is readied before surgery. Those responsible for care are expert not only in resuscitative techniques but also in their ability to detect normal and abnormal infant responses. After birth, if the infant’s
condition permits and the mother is awake, the baby may
be placed skin-to-skin on the mother or can be given to the
woman’s partner to hold (Fig. 24-12). The infant whose condition is compromised is transported after initial stabilization to the nursery for observation and the implementation
of appropriate interventions. In some institutions, the partner may accompany the infant; if not, personnel keep the
family informed of the infant’s progress, and parent-infant
contacts are initiated as soon as possible.
If the family cannot accompany the woman during surgery, the family is directed to the surgical or obstetric waiting room. The physician then reports on the condition of
the mother and child to the family members after the birth
is completed. Family members may accompany the infant
as she or he is transferred to the nursery, giving them an opportunity to see and admire the new baby.
LEGAL TIP
Discosure of Patient Information
Some mothers or fathers want the privilege of informing family and friends of the sex of the infant (if it was
not known before birth) or other information about the
birth. Before responding to requests for such information from people waiting outside the birthing area, the
nurse should check to see if the mother has given consent for such information to be released.
Immediate postoperative care. Once surgery
is completed, the mother is transferred to a recovery room
or back to her labor room. After a cesarean birth, women
have both postoperative and postpartum needs that must be
A
B
Fig. 24-12 A, Parents and their newborn. The physician manually removes the placenta, suctions the remaining amniotic fluid and blood from the uterine cavity, and closes the uterine incision, peritoneum, muscle layer, fatty tissue, and finally the skin, while the new family shares some
time together. B, Parents become better acquainted with their newborn while mother rests after
surgery. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
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addressed. They are surgical patients as well as new mothers. Nursing assessments in this immediate postbirth period
follow agency protocol and include degree of recovery from
the effects of anesthesia, postoperative and postbirth status,
and degree of pain. A patent airway is maintained, and the
woman is positioned to prevent possible aspiration. Vital
signs are taken every 15 minutes for 1 to 2 hours or until stable. The condition of the incisional dressing, the fundus, and
the amount of lochia are assessed, as well as the intravenous
intake and the urine output through the Foley catheter. The
woman is helped to turn and do coughing, deep-breathing,
and leg exercises. Medications to relieve pain may be administered.
If the baby is present, the mother and her partner are
given some time alone with him or her to facilitate bonding and attachment. Breastfeeding can be initiated if the
mother feels like trying. If the woman is in a recovery area
or in her labor room, she usually is transferred to the postpartum unit after 1 to 2 hours or once her condition is stable and the effects of anesthesia have worn off (i.e., she is
alert, oriented, and able to feel and move extremities) (Care
Path).
Postoperative or postpartum care. The attitude of the nurse and other health team members can influence the woman’s perception of herself after a cesarean
birth. The caregivers should stress that the woman is a new
mother first and a surgical patient second. This attitude helps
the woman perceive herself as having the same problems and
needs as other new mothers, while requiring supportive postoperative care.
The women’s physiologic concerns for the first few days
may be dominated by pain at the incision site and pain resulting from intestinal gas, and hence the need for pain relief. If epidural anesthesia was used for the surgery, epidural
opioids can be given in the immediate postoperative period
to provide pain relief for approximately 24 hours. Otherwise,
pain medications usually are given every 3 to 4 hours, or
patient-controlled analgesia may be ordered instead. Other
comfort measures such as position changes, splinting of the
incision with pillows, and relaxation and breathing techniques (e.g., those learned in childbirth classes) may be implemented. Women are often the best judges of what their
bodies need and can tolerate, including the postoperative ingestion of foods and fluids. If desired by the woman, the
early introduction of solid food is safe. Women who eat early
have been found to require less analgesia, and gastrointestinal problems do not occur (Abrams, Minassian, &
Pickett, 2004). Ambulation and rocking in a rocking chair
may relieve gas pains, and avoiding the consumption of gasforming foods and carbonated beverages may help minimize
them.
Nurses must be alert to a woman’s physiologic needs,
managing care to ensure adequate rest and pain relief.
Mother-baby care (couplet care) for a cesarean birth mother
may need to be modified according to her physiologic limitations as a surgical patient.
Daily care includes perineal care, breast care, and routine
hygienic care, including showering after the dressing has
been removed (if showering is acceptable according to the
women’s cultural beliefs and practices). The nurse assesses
the woman’s vital signs, incision, fundus, and lochia according to hospital policies, procedures, or protocols. Breath
sounds, bowel sounds, circulatory status of lower extremities, and urinary and bowel elimination also are assessed. It
is important to note maternal emotional status.
During the postpartum period, the nurse also can provide
care that meets the psychologic and teaching needs of mothers who have had cesarean births. The nurse can explain postpartum procedures to help the woman participate in her recovery from surgery. The nurse can help the woman plan
care and visits from family and friends that will allow adequate rest periods. Information on and assistance with infant care can facilitate adjustment to her role as a mother.
The woman is supported as she breastfeeds her baby by receiving individualized assistance to comfortably hold and
position the baby at her breast. The side-lying position and
the use of pillows to support the newborn can enhance comfort and facilitate successful breastfeeding. The partner can
be included in infant teaching sessions, and in explanations
about the woman’s recovery. The couple also should be encouraged to express their feelings about the birth experience.
Some parents are angry, frustrated, or disappointed that a
vaginal birth was not possible. Some women express feelings
of low self-esteem or a negative self-image. Others express
relief and gratitude that the baby is healthy and safely born.
It may be helpful for them to have the nurse who was present during the birth visit and help fill in “gaps” about the
experience. Other psychologic and lifestyle concerns that
have been reported include depression, feeling limited in activities, and changes in family interactions (Gamble &
Creedy, 2004).
Discharge after cesarean birth is usually by the third postoperative day. The time is often determined by criteria established by the woman’s insurance carrier or the federal government (e.g., diagnosis-related groups).
The Newborn’s and Mother’s Health Protection Act of
1996 provides for a length of stay of up to 96 hours for cesarean births. These criteria may not coincide with the woman’s physical or psychosocial readiness for discharge. Some
states have added home care provisions for mothers who
meet appropriate criteria for discharge and choose to leave
sooner than the allowed length of stay. This policy recognizes that home care is less costly than hospital care and in
most cases is more beneficial for recovery.
The nurse provides discharge teaching to prepare women
for self-care and newborn care in a limited time, while trying to ensure that the woman is comfortable and able to rest.
Discharge teaching and planning should include information
about nutrition; measures to relieve pain and discomfort; exercise and specific activity restrictions; time management
that includes periods of uninterrupted rest and sleep; hygiene, breast, and incision care; timing for resumption of
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C A R E PAT H
24
Labor and Birth at Risk
805
Cesarean Birth without Complications: Expected Length of
Stay—48 to 72 Hours
IMMEDIATE
POSTOP
CESAREAN
BY FOURTH
HOUR AFTER
ADMISSION
TO PP UNIT
ASSESSMENTS
Recovery room
or PACU admission assessment
complete
PP admission
assessment
and care
plan completed
Vital Signs
q15min 1 hr;
q30min 4
hr, WNL
Postpartum
Assessment
5 TO 24
HOURS
25 TO 48
HOURS
BY DISCHARGE
q1h 3, WNL
q4-8h, WNL
q8h, WNL
q8h, WNL
q15min 1 hr,
WNL
q1h 3, WNL
q4-8h, WNL
q8-12h, WNL
q8-12h, WNL
Abdominal
Incision
Dressing dry
and intact
Dressing dry
and intact
Dressing dry and
intact
Dressing off or
changed, incision intact
Incision intact; staples may be removed and SteriStrips in place,
incision WNL
Genitourinary
Retention
catheter output 30 ml/hr
Retention
catheter
output
30 ml/hr
Retention
catheter output
30 ml/hr;
usually discontinued by
24 hours
Catheter discontinued, output
100 ml/void
or 240 ml/8 hr
Urine output
240 ml/8 hr
Absent or hypoactive BS
Hypoactive to
active BS
Active BS flatus
Active BS flatus;
may or may not
have BM
Alert and
oriented,
moving all
extremities
Ambulating with
help
Ambulating
unassisted
Ambulating ad lib
Parent-infant
bonding continues
Parent-infant
bonding
progressing
Intrapartal CBC
results on chart
or computer;
determine
Rh status
and need for
anti-Rh globulin; check
for rubella
immunity
PP HCT WNL,
give anti-Rh
globulin if
indicated
Gastrointestinal
Musculoskeletal
Alert or easily
aroused, can
move legs
Bonding
Evidence of
parent-infant
bonding; first
breastfeeding
if desired
Laboratory Tests
Give rubella vaccine
if indicated
BS, bowel sounds; BM, bowel movement; CBC, complete blood count; HCT, hematocrit; PACU, postanesthesia care unit; Postop, postoperative; PP, postpartum; WNL, within normal limits
Continued
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C A R E PAT H
Cesarean Birth without Complications: Expected Length of
Stay—48 to 72 Hours—cont’d
IMMEDIATE
POSTOP
CESAREAN
BY FOURTH
HOUR AFTER
ADMISSION
TO PP UNIT
5 TO 24
HOURS
25 TO 48
HOURS
IV
IV continues
IV continues
IV continues
IV may be
discontinued
Diet
NPO
Ice chips, sips
of clear
liquids
Clear liquids
Regular diet or as
tolerated
Pericare by
nurse
Pericare with
help
Self-pericare
BY DISCHARGE
INTERVENTIONS
Perineal
Activity
Bed rest
Bed rest
OOB 3 with
help, ADLs assisted, assisted
to comfortable
position to
hold and feed
baby
Holds baby comfortably, ambulates without
assistance,
ADLs unassisted
Pulmonary
Care
Patent airway;
O2 discontinued
TCDB q2h with
splinting, incentive
spirometry
q1h if ordered, lungs
clear
TCDB q2h, continue incentive
spriometry if
ordered while
awake; lungs
clear
TCDB as needed;
lungs clear
Medications
Oxytocin added
to IV
Pain control:
analgesics,
IV, or epidural
narcotic as
ordered
Oxytocin
continued
Pain control:
analgesics—
PCA, IM, PO,
or epidural
narcotic as
ordered
Oxytocin may be
discontinued
Pain control: IM,
PO, PCA narcotics or analgesics as
needed
Oxytocin discontinued
Pain control: PO
analgesics,
NSAIDs as
needed; PCA
discontinued;
stool softener,
PNV as ordered
Regular diet
Activity ad lib
Rx filled or given to
take home
ADLs, activities of daily living; IM, intramuscularly; IV, intravenous; NPO, nothing by mouth; NSAIDs, nonsteroidal antiinflammatory drugs; OOB, out of
bed; PCA, patient-controlled analgesia; PNV, prenatal vitamins; PO, nothing by mouth; Rx, prescription; TCDB, turn, cough, deep breathe
sexual activity and contraception; signs of complications
(see Teaching Guidelines: Patient Instructions for Self-Care:
on p. 808) and infant care. The nurse assesses the woman’s
need for continued support or counseling to facilitate her
emotional recovery from the birth. The woman’s family and
friends should be educated regarding her needs during the
recovery process, and their assistance should be coordinated
before discharge. Referral to support groups or to community agencies may be indicated to promote the recovery
process further. A postdischarge program of telephone follow-up and home visits can facilitate the woman’s full recovery after cesarean birth.
Vaginal birth after cesarean
Indications for primary cesarean birth, such as dystocia,
breech presentation, or fetal distress, often are nonrecurring.
Therefore a woman who has had a cesarean birth may subsequently become pregnant and not have any contraindications to labor and vaginal birth in that pregnancy and may
attempt a vaginal birth after cesarean (VBAC).
ACOG (2004a) encourages a TOL and VBAC attempt in
women who have had one previous cesarean birth by low
transverse incision. Vaginal birth is relatively safe, but there
is risk for uterine rupture through a lower uterine segment
scar. Increased reports of uterine rupture in the United States
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C A R E PAT H
Labor and Birth at Risk
807
Cesarean Birth without Complications: Expected Length of
Stay—48 to 72 Hours—cont’d
IMMEDIATE
POSTOP
CESAREAN
Teaching,
Discharge Plan
24
Breastfeeding,
positioning,
leg exercises
BY FOURTH
HOUR AFTER
ADMISSION
TO PP UNIT
Verbalize understanding
and unit
routines,
how to
achieve rest,
TCDB, involution, pain
control
5 TO 24
HOURS
25 TO 48
HOURS
Self: comfort
measures and
care; reinforce
TCDB and positioning; introduce teaching
videos, lactation promotion
or suppression
Infant: Handwashing, infant
safety, positioning for feeding
and burping; if
breastfeeding,
then positioning baby, latching on, timing,
removing from
breast
Self: diet; activity
and rest; bowel
and bladder
function;
perineal care
Infant: bonding;
parent concerns; feeding;
infant bath,
cord care; need
for car seat;
newborn characteristics; circumcision care
if procedure
performed; answer questions
and Canada in the 1990s have raised concerns about the
safety of VBAC. Labor and vaginal birth are not recommended if there are contraindications, such as a previous fundal classic cesarean scar, a scar from uterine surgery, or evidence of CPD. Women are strongly advised against
attempting VBACs in birth centers because the health risks
are too great (Bowes & Thorp, 2004; Lieberman, Ernst,
Rooks, Stapleton, & Flamm, 2004).
Women are most often the primary decision makers with
regard to choice of birth method. During the antepartal period, the woman should be given information about VBAC
and encouraged to choose it as an alternative to repeat cesarean birth, as long as no contraindications exist (Ridley,
BY DISCHARGE
Self: home care,
signs of complications (infections,
bleeding), normal
psychologic adjustments, normal
ADLs; resumption
of sexual activities; contraception; identification
of support system
at home; selfconcept issues related to cesarean
birth. Inform
whom to call if
problems; review
need to keep
follow-up appointment; provide information about
community resources; provide
copy of home care
instructions
Infant: parents to
demonstrate infant care; reinforce use of booklets for infant
care, whom to call
if problems; discuss immunization needs; review
need to keep follow-up appointments
Davis, Bright, & Sinclair, 2002). VBAC support groups and
prenatal classes can help prepare the woman psychologically
for labor and vaginal birth.
This labor should occur in a hospital facility that has the
equipment and personnel available to begin the surgery
within 30 minutes from the time a decision is made to perform cesarean birth (ACOG, 2004a). Ideally the woman is
admitted to the labor and birth unit at the onset of spontaneous labor. In the latent phase of labor, the nurse encourages her to engage in normal activities such as ambulation. In the active phase of labor, FHR and pattern and
uterine activity usually are monitored electronically, and intravenous access such as a saline lock may be established. The
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TEACHING GUIDELINES
Postpartum Pain Relief after
Cesarean Birth
Evolve/CD: Case Study—Postdate Pregnancy
INCISIONAL
•
•
•
Splint incision with a pillow when moving or coughing.
Use relaxation techniques such as music, breathing,
and dim lights.
Apply a heating pad to the abdomen.
feelings about having another cesarean birth. It is very important that this outcome not be labeled a failed VBAC.
Evaluation
To evaluate the effectiveness of nursing care for a woman experiencing dystocia, the nurse reviews the expected outcomes
of care that were met and assesses the woman’s and the family’s level of satisfaction with the care received.
GAS
•
•
•
•
•
•
Walk as often as you can.
Do not eat or drink gas-forming foods, carbonated beverages, or whole milk.
Do not use straws for drinking fluids.
Take antiflatulence medication if prescribed.
Lie on your left side to expel gas.
Rock in a rocking chair.
PATIENT INSTRUCTIONS
FOR SELF-CARE
Signs of Postoperative
Complications after Discharge
Report the following signs to your health care provider:
• Temperature exceeding 38° C
• Painful urination
• Lochia heavier than a normal period
• Wound separation
• Redness or oozing at the incision site
• Severe abdominal pain
physician or nurse-midwife should be immediately available
during active labor.
There is no evidence that administering oxytocin to induce or augment labor or the use of epidural anesthesia is
contraindicated, although caution and close monitoring of
the laboring woman are urged if these are used (Bowes &
Thorp, 2004). However, use of prostaglandins, especially
misoprostol (prostaglandin E1), to ripen the cervix or induce
labor is not recommended because they have been associated with an increased risk for uterine rupture (ACOG,
2004a).
Attention should be paid to the woman’s psychologic, as
well as physical, needs during the TOL. Anxiety increases the
release of catecholamines and can inhibit the release of oxytocin, thus delaying the progress of labor and possibly leading to a repeat cesarean birth. To alleviate such anxiety, the
nurse can encourage the woman to use breathing and relaxation techniques and to change positions to promote labor progress. The woman’s partner can be encouraged to
provide comfort measures and emotional support. Collaboration among the woman in labor, her partner, the nurse,
and other health care providers often results in a successful
VBAC. If a TOL does not proceed to vaginal birth, the
woman will need support and encouragement to express her
POSTTERM PREGNANCY,
LABOR, AND BIRTH
A postterm pregnancy (also called postdate) is one that extends beyond the end of week 42 of gestation, or 294 days
from the first day of the last menstrual period. The incidence
of postterm pregnancy is estimated to be between 4% and
14%, with an average of 10% (Resnik & Resnik, 2004).
Many pregnancies are misdiagnosed as prolonged. This
can occur because the pregnancy is inaccurately dated because the woman has an irregular menstrual cycle pattern,
an accurate date of the last menstrual period is unknown, or
entry into prenatal care was delayed or did not occur.
Although the exact cause of postterm pregnancy is still
unknown, a possible cause may be deficiency of placental
estrogen and continued secretion of progesterone. Low levels of estrogen may result in a decrease in prostaglandin precursors and reduced formation of oxytocin receptors in the
myometrium (Gilbert & Harmon, 2003). A woman who experiences one postterm pregnancy is more likely to experience it again in subsequent pregnancies (Divon, 2002).
Clinical manifestations of postterm pregnancy include
maternal weight loss (more than 1.4 kg/wk) and decreased
uterine size (related to decreased amniotic fluid), meconium
in the amniotic fluid, and advanced bone maturation of the
fetal skeleton with an exceptionally hard fetal skull (Gilbert
& Harmon, 2003).
Maternal and Fetal Risks
Maternal risks are often related to the birth of an excessively
large infant. The woman is at increased risk for dysfunctional
labor; birth canal trauma, including perineal lacerations and
extension of episiotomy during vaginal birth; postpartum
hemorrhage; and infection. Interventions such as induction
of labor with prostaglandins or oxytocin, forceps- or vacuumassisted birth, and cesarean birth are more likely to be necessary. The woman also may experience fatigue and psychologic reactions such as depression, frustration, and
feelings of inadequacy as she passes her estimated date of
birth (ACOG, 2000; Gilbert & Harmon, 2003).
Fetal risks appear to be twofold. The first is the possibility of prolonged labor, shoulder dystocia, birth trauma, and
asphyxia from macrosomia. Macrosomia occurs when the
placenta continues to provide adequate nutrients to support
fetal growth after 40 weeks of gestation. It is estimated to occur in approximately 25% of prolonged pregnancies (Divon,
2002). The second risk is the compromising effects on the
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Critical Thinking Exercise
Postterm Pregnancy
Shelly is 36 years old, G2, P1001, at 41 weeks of gestation. She was sent to the perinatal unit at the antepartal
clinic for a biophysical profile. She asks why she just can’t
be admitted to the Labor and Birth Unit and have a cesarean birth. How will you respond to her question?
1 Is there sufficient evidence to draw conclusions about
the benefits of cesarean birth for postterm pregnancy?
2 What assumptions can be made about the following
issues?
a. Elective cesarean for postterm pregnancy
b. Timing of induction of labor for postterm pregnancy.
c. Antepartal testing for postterm pregnancy
3 What implications and priorities for nursing care can
be drawn at this time?
4 Does the evidence objectively support your conclusion?
5 Are there alternative perspectives to your conclusion?
fetus of an “aging” placenta. Placental function gradually decreases after 37 weeks of gestation. Amniotic fluid volume
declines to approximately 800 ml by 40 weeks of gestation
and to about 400 ml by 42 weeks of gestation. The resulting oligohydramnios can lead to fetal hypoxia related to cord
compression. If placental insufficiency is present, there is a
high likelihood of signs of non-reassuring fetal status occurring during labor. Neonatal problems may include
asphyxia, meconium aspiration syndrome, dysmaturity syndrome, hypoglycemia, polycythemia, and respiratory distress
(Gilbert & Harmon, 2003). Whether an infant born after a
postterm pregnancy has neurologic, behavioral, intellectual,
or developmental problems must be further investigated.
Collaborative Care
The management of postterm pregnancy is still controversial. The induction of labor at 41 to 42 weeks is suggested
by some authorities as a means of reducing the rate of cesarean birth and stillbirth or neonatal death (ACOG, 2004b;
Resnik & Resnik, 2004). Others follow a more individualized
approach, allowing the pregnancy to proceed to 43 weeks of
gestation as long as assessment of fetal well-being with a combination of tests is performed and the results of the tests are
normal. Tests are usually performed on a weekly or twiceweekly basis (ACOG, 2004b; Divon, 2002; Myers et al.,
2002).
Antepartum assessments for postterm pregnancy may
include daily fetal movement counts, NSTs, AFV assessments, contraction stress tests (CSTs), BPPs, and Doppler
flow measurements. The BPP may be the best way of gauging fetal well-being because it combines nonstress testing
with real-time ultrasound scanning to assess fetal movements,
fetal breathing movements, and the AFV. Determining the
AFV is critical in women with postterm pregnancies because
24
Labor and Birth at Risk
809
a decreased AFV (i.e., oligohydramnios) has been associated
with fetal stress. The woman and her family should be fully
informed regarding the tests, including why they are performed and the meaning of the results obtained in terms of
the health of the mother and fetus.
Cervical checks usually are performed weekly after 40
weeks of gestation to determine whether the condition of the
cervix is favorable for induction (5 or greater on the Bishop
score for multiparas and 9 or more for nulliparas) (see Table
24-3). Vaginal secretions may be assessed for the amount of
fetal fibronectin; a low concentration may predict increased
risk for prolonged pregnancy, but results of studies have thus
far been inconclusive (Divon, 2002; Gilbert & Harmon, 2003).
During the postterm period, the woman is encouraged to
assess fetal activity daily, assess for signs of labor, and keep
appointments with her primary health care provider (Patient
Instructions for Self-Care). The woman and her family
should be encouraged to express their feelings (e.g., frustration, anger, impatience, fear) about the prolonged pregnancy and should be helped to realize that these feelings
are normal. At times the emotional and physical strain of a
postterm pregnancy may seem insurmountable. Referral to
a support group or another supportive resource may be
needed.
If the woman’s cervix is favorable, labor is usually induced
with oxytocin. If not, continued fetal surveillance or a cervical ripening agent (e.g., prostaglandin insert or gel) may be
administered, followed by oxytocin induction (ACOG,
2004b; Gilbert & Harmon, 2003; Resnik & Resnik, 2004).
The fetus of a woman with a postterm pregnancy should
be monitored electronically for a more accurate assessment
of the FHR and pattern. Fetal scalp pH sampling or fetal
oxygen saturation monitoring may be done to determine
whether acidosis is occurring. Inadequate fluid volume leads
to compression of the cord, which results in fetal hypoxia
that is reflected in variable or prolonged deceleration patterns
and passage of meconium. If oligohydramnios is present, an
amnioinfusion may be performed to restore amniotic fluid
volume to maintain a cushioning of the cord. The use of amnioinfusion to treat fetal distress associated with oligohydramnios in labor is a form of care likely to be beneficial
(Enkin et al., 2000).
PATIENT INSTRUCTIONS
FOR SELF-CARE
Postterm Pregnancy
•
•
•
•
•
Perform daily fetal movement counts.
Assess for signs of labor.
Call your primary health care provider if your membranes rupture or if you perceive a decrease in or no
fetal movement.
Keep appointments for fetal assessment tests or cervical checks.
Come to the hospital soon after labor begins.
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Emotional support is essential for the woman with a postterm pregnancy and her family. A vaginal birth is anticipated,
but the couple should be prepared for a forceps-assisted,
vacuum-assisted, or cesarean birth if complications arise.
Expected outcomes of care include that the woman and
her family use appropriate coping mechanisms to deal with
the emotional aspects of her postterm pregnancy and that
the woman and her newborn experience no injury during the
birth.
OBSTETRIC EMERGENCIES
Shoulder Dystocia
Shoulder dystocia is an uncommon obstetric emergency
that increases the risk for fetal and maternal morbidity and
mortality during the attempt to deliver the fetus vaginally.
It is a condition in which the head is born, but the anterior
shoulder cannot pass under the pubic arch. FPD related to
excessive fetal size (greater than 4000 g) or maternal pelvic
abnormalities may be a cause of shoulder dystocia, although
shoulder dystocia can occur in the absence of any known risk
factors. The nurse should be observant for signs that could
indicate the presence of shoulder dystocia, including slowing of the progress of labor and formation of a caput succedaneum that increases in size. When the head emerges, it
retracts against the perineum (turtle sign), and external rotation does not occur (Bowes & Thorp, 2004).
The fetus is more likely to experience birth injuries related
to asphyxia, brachial plexus damage, and fracture, especially
of the humerus or clavicle. The mother’s primary risk stems
from excessive blood loss as a result of uterine atony or rupture, lacerations, extension of the episiotomy, or endometritis. It is estimated that 0.24% to 2% of all vaginal
births are complicated by shoulder dystocia (Bowes & Thorp,
2004).
Collaborative care
Many maneuvers such as suprapubic pressure and maternal position changes have been suggested and tried to free
the anterior shoulder, although no one particular maneuver
has been found to be most effective (Bowes & Thorp, 2004).
Suprapubic pressure can be applied to the anterior shoulder
by using the Mazzanti or Rubin technique (Fig. 24-13) in an
attempt to push the shoulder under the symphysis pubis
(Baskett, 2002).
In the McRoberts maneuver (Fig. 24-14), the woman’s legs
are flexed apart, with her knees on her abdomen (Baskett,
2002; Baxley & Gobbo, 2004). This maneuver causes the
sacrum to straighten, and the symphysis pubis rotates toward
the mother’s head; the angle of pelvic inclination is decreased, freeing the shoulder. Suprapubic pressure can be applied at this time. The McRoberts maneuver is the preferred
method when a woman is receiving epidural anesthesia.
Having the woman move to the hands-and-knees position
(the Gaskin maneuver), squatting position, or lateral recumbent position also has been used to resolve cases of
shoulder dystocia (Baskett, 2002; Bowes & Thorp, 2004).
Fundal pressure is usually not advised as a method of relieving shoulder dystocia (Nocon, 2000; Simpson & Knox,
2001).
When shoulder dystocia is diagnosed, the nurse helps the
woman to assume the position(s) that may facilitate birth of
the shoulders, assists the primary health care provider with
these maneuvers and techniques during birth, and documents the maneuvers. The nurse also provides encouragement and support to reduce anxiety and fear.
Newborn assessment should include examination for fracture of the clavicle or humerus as well as brachial plexus injuries and asphyxia (Bowes & Thorp, 2004). Maternal assessment should focus on early detection of hemorrhage and
trauma to the soft tissue of the birth canal.
A
B
Fig. 24-13 Application of suprapubic pressure. A, Mazzanti technique. Pressure is applied directly posteriorly and laterally above the symphysis pubis. B, Rubin technique. Pressure is applied
obliquely posteriorly against the anterior shoulder.
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Labor and Birth at Risk
811
If the presenting part does not fit snugly into the lower
uterine segment (e.g., as in hydramnios), when the membranes rupture, a sudden gush of amniotic fluid may cause
the cord to be displaced downward. Similarly the cord may
prolapse during amniotomy if the presenting part is high. A
small fetus may not fit snugly into the lower uterine segment;
as a result, cord prolapse is more likely to occur.
Fig. 24-14 McRoberts maneuver. (Modified from Lanni,
S., & Seeds, J. [2002]. Malpresentations. In S. Gabbe, J. Niebyl,
& J. Simpson (Eds.), Obstetrics: Normal and problem pregnancies [4th ed.]. New York: Churchill Livingstone.)
Prolapsed Umbilical Cord
Prolapse of the umbilical cord occurs when the cord lies below the presenting part of the fetus. Umbilical cord prolapse
may be occult (hidden, not visible) at any time during labor
whether or not the membranes are ruptured (Fig. 24-15, A
and B). It is most common to see frank (visible) prolapse directly after rupture of membranes, when gravity washes the
cord in front of the presenting part (Fig. 24-15, C and D).
Contributing factors include a long cord (longer than 100
cm), malpresentation (breech), transverse lie, or unengaged
presenting part.
A
B
Collaborative care
Prompt recognition of a prolapsed umbilical cord is important because fetal hypoxia resulting from prolonged cord
compression (i.e., occlusion of blood flow to and from the
fetus for more than 5 minutes) usually results in central nervous system damage or death of the fetus. Pressure on the
cord may be relieved by the examiner putting a sterile gloved
hand into the vagina and holding the presenting part off of
the umbilical cord (Fig. 24-16, A and B). The woman is assisted into a position such as a modified Sims (Fig. 24-16,
C), Trendelenburg, or knee-chest (Fig. 24-16, D) position, in
which gravity keeps the pressure of the presenting part off
the cord. If the cervix is fully dilated, a forceps- or vacuumassisted birth can be performed for the fetus in a cephalic
presentation; otherwise, a cesarean birth is likely to be performed. Nonreassuring FHR patterns, inadequate uterine
relaxation, and bleeding also can occur as a result of a prolapsed umbilical cord. Indications for immediate interventions are presented in the Emergency box on p. 813. Ongoing assessment of the woman and her fetus is critical to
determine the effectiveness of each action taken. The woman
and her family are often aware of the seriousness of the situation; therefore the nurse must provide support by giving
explanations for the interventions being implemented and
their effect on the status of the fetus.
Rupture of the Uterus
Rupture of the uterus is a rare but very serious obstetric
injury that occurs in 1 in 1500 to 2000 births. The most
C
D
Fig. 24-15 Prolapse of umbilical cord. Note pressure of presenting part on umbilical cord, which
endangers fetal circulation. A, Occult (hidden) prolapse of cord. B, Complete prolapse of cord. Note
that membranes are intact. C, Cord presenting in front of the fetal head may be seen in vagina.
D, Frank breech presentation with prolapsed cord.
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A
B
C
D
Fig. 24-16 Arrows indicate direction of pressure against presenting part to relieve compression of prolapsed umbilical cord. Pressure exerted by examiner’s fingers in A, vertex presentation,
and B, breech presentation. C, Gravity relieves pressure when woman is in modified Sims position with hips elevated as high as possible with pillows. D, Knee-chest position.
frequent causes of uterine rupture during pregnancy are separation of the scar of a previous classic cesarean birth, uterine trauma (e.g., accidents, surgery), and a congenital uterine anomaly. During labor and birth, uterine rupture may be
caused by intense spontaneous uterine contractions, labor
stimulation (e.g., oxytocin, prostaglandin), an overdistended
uterus (e.g., multifetal gestation), malpresentation, external
or internal version, or a difficult forceps-assisted birth. It occurs more commonly in multigravidas than in primigravidas.
A uterine rupture is classified as either complete or incomplete. A complete rupture extends through the entire
uterine wall into the peritoneal cavity or broad ligament. An
incomplete rupture extends into the peritoneum but not into
the peritoneal cavity or broad ligament. Bleeding is usually
internal. An incomplete rupture also may be a partial separation at an old cesarean scar and may go unnoticed unless
the woman undergoes a subsequent cesarean birth or other
uterine surgery.
Signs and symptoms vary with the extent of the rupture
and may be silent or dramatic. In an incomplete rupture,
pain may not be present. The fetus may or may not have late
decelerations, decreased variability, an increased or decreased
heart rate, or other nonreassuring signs. The woman may experience vomiting, faintness, increased abdominal tenderness, hypotonic uterine contractions, and lack of progress.
Eventually, bleeding and the effects of blood loss will be
noted. Fetal heart tones may be lost. In a complete rupture,
the woman may complain of sudden, sharp shooting abdominal pain and may state that “something gave way.” If
she is in labor, her contractions will cease, and pain is relieved. She may exhibit signs of hypovolemic shock caused
by hemorrhage (i.e., hypotension, tachypnea, pallor, and
cool, clammy skin). If the placenta separates, the FHR will
be absent. Fetal parts may be palpable through the abdomen.
The nurse should suspect pulmonary embolism if the
woman complains of chest pain.
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EMERGENCY
Prolapsed Cord
SIGNS
•
•
•
Fetal bradycardia with variable deceleration during
uterine contraction.
Woman reports feeling the cord after membranes
rupture.
Cord is seen or felt in or protruding from the vagina.
INTERVENTIONS
•
•
•
•
•
•
•
•
•
•
Call for assistance.
Notify primary health care provider immediately.
Glove the examining hand quickly and insert two fingers into the vagina to the cervix. With one finger on
either side of the cord or both fingers to one side, exert upward pressure against the presenting part to relieve compression of the cord (Fig. 24-16, A and B).
Place a rolled towel under the woman’s right or left hip.
Place woman into the extreme Trendelenburg or a modified Sims position (Fig. 24-16, C), or a knee-chest position (Fig. 24-16, D).
If cord is protruding from vagina, wrap loosely in a sterile towel saturated with warm sterile normal saline solution.
Administer oxygen to the woman by mask at 8 to
10 L/min until birth is accomplished.
Start IV fluids or increase existing drip rate.
Continue to monitor FHR by internal fetal scalp electrode, if possible.
Explain to woman and support person what is happening and the way it is being managed.
Prepare for immediate vaginal birth if cervix is fully dilated or cesarean birth if it is not.
Collaborative care
Prevention is the best treatment. Women who have had
a previous classic cesarean birth are advised not to attempt
vaginal birth in subsequent pregnancies. Women at risk for
uterine rupture are assessed closely during labor. Women
whose labor is induced with oxytocin or prostaglandin (especially if their previous birth was cesarean) are monitored
for signs of uterine hyperstimulation, because this can precipitate uterine rupture. If hyperstimulation occurs, the oxytocin infusion is discontinued or decreased, and a tocolytic
medication may be given to decrease the intensity of the
uterine contractions. After giving birth, women are assessed
for excessive bleeding, especially if the fundus is firm and
signs of hemorrhagic shock are present.
If rupture occurs, the type of medical management depends on the severity. A small rupture may be managed with
a laparotomy and birth of the infant, repair of the laceration,
and blood transfusions, if needed. For a complete rupture,
hysterectomy and blood replacement is the usual treatment.
The nurse’s role may include starting intravenous fluids,
transfusing blood products, administering oxygen, and
assisting with the preparation for immediate surgery. Supporting the woman’s family and providing information
24
Labor and Birth at Risk
813
about the treatment is important during this emergency. The
associated fetal mortality rate is high (50% to 75%), and the
maternal mortality rate may be high if the woman is not
treated immediately (Cunningham et al., 2005). Providing
information about spiritual support services or suggesting
that the family contact their own support system may be warranted.
Amniotic Fluid Embolism
Amniotic fluid embolism (AFE) occurs when amniotic fluid
containing particles of debris (e.g., vernix, hair, skin cells, or
meconium) enters the maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory
collapse. This can occur because fluid can enter the maternal circulation any time there is an opening in the amniotic
sac or maternal uterine veins. Although rare, this complication is estimated to be the cause of 10% of maternal deaths
in the United States. The fetal mortality rate is estimated to
be as high as 30%, and 50% of the surviving infants will have
neurologic damage (Cunningham et al., 2005)
Amniotic fluid is more damaging if it contains meconium
and other particulate matter such as mucus, fat globules,
lanugo, bacterial products, or debris from a dead fetus because emboli can then form more readily. Maternal death
occurs most often when thick meconium is present in
the amniotic fluid, because this clogs the pulmonary veins
more completely than other debris. Even if death does not
occur immediately, serious coagulation problems such as
disseminated intravascular coagulopathy (see Chapter 26)
usually occur (Cunningham et al., 2005).
Collaborative care
The immediate interventions for AFE are summarized in
the Emergency box on p. 814. Such medical management
must be instituted immediately. Cardiopulmonary resuscitation is often necessary. The woman is usually placed on
mechanical ventilation, and blood replacement is initiated;
coagulation defects are treated. Although the incidence of
possible complications is small, their immediate recognition
and prompt initiation of treatment are important.
NURSE ALERT Automatic blood pressure devices, FHR
monitors, and pulse oximeters may be inadequate and
inaccurate during extreme clinical conditions. Assessment by a competent nurse is often more accurate than
that provided by any one piece of equipment (Curran,
2003).
The nurse’s immediate responsibility is to assist with the
resuscitation efforts. If the woman survives, she is usually
moved to a critical care unit, where hemodynamic monitoring, blood replacement, and coagulopathy treatment are
implemented. If cardiopulmonary arrest occurs, for optimal
fetal survival, a perimortem cesarean birth should occur
within 5 minutes (Curran, 2003).
Support of the woman’s partner and family is needed;
they will be anxious and distressed. Brief explanations of
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what is happening are important during the emergency and
can be reinforced after the immediate crisis is over. If the
woman dies, emotional support and involvement of the perinatal loss support team or other resource for grief counsel-
ing is needed. Referral to grief and loss support groups would
be appropriate (see Chapter 28). The nursing staff also may
need help in coping with feelings and emotions that result
from a maternal death.
EMERGENCY
Amniotic Fluid Embolism
INTERVENTIONS
Oxygenate
SIGNS
Respiratory Distress
•
•
•
•
•
•
Restlessness
Dyspnea
Cyanosis
Pulmonary edema
Respiratory arrest
•
•
Maintain cardiac output and replace fluid losses
•
•
•
•
Circulatory Collapse
•
•
•
•
Administer oxygen by face mask (8 to 10 L/min) or resuscitation bag delivering 100% oxygen.
Prepare for intubation and mechanical ventilation.
Initiate or assist with cardiopulmonary resuscitation. Tilt
pregnant woman 30 degrees to side to displace uterus.
Hypotension
Tachycardia
Shock
Cardiac arrest
Position woman on her side.
Administer intravenous fluids.
Administer blood: packed cells, fresh frozen plasma.
Insert indwelling catheter, and measure hourly urine
output.
Hemorrhage
Correct coagulation failure
•
Monitor fetal and maternal status
•
Coagulation failure: bleeding from incisions, venipuncture sites, trauma (lacerations); petechiae, ecchymoses,
purpura
Uterine atony
Prepare for emergency birth once woman’s
condition is stabilized
Provide emotional support to woman, her
partner, and family
COMMUNITY ACTIVITY
Meet with different childbirth educators in the community (e.g., at the health department, at the hospital clinic or birth center, or private practice educator) whose class participants plan to give birth at
your hospital. Evaluate what information pregnant
couples are given about measures they can use to
enhance the woman’s progress in labor and reduce
the possibility of unwanted interventions such as
labor augmentation or cesarean birth. Offer suggestions to the educators based on evidence-based
practice if needed.
Key Points
•
Preterm labor is cervical change and uterine contractions occurring between 20 weeks and 37
weeks of pregnancy; preterm birth is any birth that
occurs before the completion of 37 weeks of pregnancy.
•
The cause of preterm labor is unknown and is assumed to be multifactorial; therefore it is not possible to predict with certainty which women will
experience preterm labor and birth.
•
Because the onset of preterm labor is often insidious and can be mistaken for normal discomforts of pregnancy, nurses should teach all pregnant women how to detect the early symptoms of
preterm labor and to call their primary health care
provider when symptoms occur.
•
Bed rest, a commonly prescribed intervention for
preterm labor, has many deleterious side effects
and has never been shown to decrease preterm
birth rates.
•
Research has demonstrated that a gain of 48 hours
to several days is the best outcome that can be expected with the use of tocolytics. The best reason
to use tocolytic therapy is to achieve sufficient
time to administer glucocorticoids in an effort to
accelerate fetal lung maturity and reduce the severity of respiratory complications in infants born
preterm.
•
Vigilance for signs of infection is a major part of
the care for women with PPROM.
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815
Key Points—cont’d
•
Dystocia results from differences in the normal relations among any of the five factors affecting labor and is characterized by differences in the pattern of progress in labor.
•
Dysfunctional labor occurs as a result of hypertonic uterine dysfunction, hypotonic uterine dysfunction, or inadequate voluntary expulsive forces.
•
The functional relations among the uterine contractions, the fetus, and the mother’s pelvis are altered by maternal positioning.
•
Uterine contractility is increased by the effects of
oxytocin and prostaglandin and is decreased by
tocolytic agents.
•
Cervical ripening using chemical or mechanical
measures can increase the success of labor induction.
•
Expectant parents benefit from learning about operative obstetrics (e.g., forceps-assisted, vacuum-
assisted, or cesarean birth) during the prenatal
period.
•
The basic purpose of cesarean birth is to preserve
the life or health of the mother and her fetus.
•
Unless contraindicated, vaginal birth is possible after a previous cesarean birth.
•
Labor management that emphasizes one-to-one
support of the laboring woman by another
woman (e.g., doula, nurse, nurse-midwife) can reduce the rate of cesarean birth and increase the
rate of VBACs.
•
A postterm pregnancy poses a risk to both the
mother and the fetus.
•
Obstetric emergencies (e.g., shoulder dystocia,
prolapsed cord, rupture of the uterus, and amniotic fluid embolism) occur rarely but require immediate intervention to preserve the health or life
of the mother and fetus.
Answer Guidelines to Critical Thinking Exercises
Preterm Labor
1 There is no evidence in the literature to support the efficacy of
bed rest in reducing preterm birth rates; it is a form of care with
unknown effectiveness (Enkin et al., 2000; Maloni, 1998). Deleterious effects of bed rest on women include decreased muscle
tone, weight loss, calcium loss, and glucose intolerance. Weeks
of bed rest lead to bone demineralization, constipation, fatigue,
isolation, anxiety, and depression.
2 a. Because this is Yolanda’s third hospitalization for preterm labor, her risks of giving birth prematurely are increased. Her
primary health care provider could choose to have her remain
hospitalized until birth to increase the chances of a good outcome for the baby.
b. Bed rest is often ordered as an intervention to prevent
preterm birth even though it is of unknown effectiveness.
Hospitalization at a facility that can handle high risk or
preterm infants increases the chances of a good outcome. Although the home is an ideal location for a pregnant woman,
the primary health care provider may have knowledge that
Yolanda would be unlikely to remain on bed rest at home
because of the need to care for her husband and child.
c. The nurse can coach Yolanda and her family in ways to reduce
the frustration and boredom that accompany restriction to
bed rest for several weeks. The environment can be modified
for convenience, and essential items placed within reach (e.g.,
telephone, television, radio, tape or compact disc player, computer with Internet access, snacks, books, magazines, newspapers, and items for hobbies). Families, who are often anxious regarding the health status of the mother and baby, may
need help in learning how to organize time and space or to
restructure family routines so that the pregnant woman can
remain a part of family activity while still maintaining bed rest.
d. The nurse can explore resources available in the community
to assist with care of Yolanda’s 2-year-old son. Referral to a
social worker can be made. Family members can be asked
to help; church and social groups can be helpful.
3 The priority for nursing care is to work with Yolanda to prevent
preterm birth. Assisting Yolanda to maintain bed rest as ordered,
providing diversions, reducing anxiety, and coaching her in ex-
ercises she can perform in bed to maintain muscle tone and prevent bone loss are actions to take. Providing explanations and
keeping the family informed are essential. The fetus and uterine contractions are monitored as required by protocol or the
primary health care provider’s orders.
4 Although bed rest has not been shown to be effective in preventing preterm birth, it is a common intervention. Therefore
the nurse can implement actions to mitigate or prevent the deleterious effects of bed rest. She can work with the family to ensure emotional support and with the social worker to ensure
child care for the 2-year-old.
5 Alternatively and importantly, the nurse can also work to ensure that an evidence base exists for care provided. The nurse
can work with other health care providers to identify and use
the best available evidence on which to base practice. The nurse
can provide evidence about the deleterious effects of bed rest
and seek to change practice.
Postterm Pregnancy
1 There is no evidence in the literature to support elective cesarean
for prolonged pregnancy when there is no maternal or fetal compromise.
2 a. Elective cesarean for any pregnant woman, whether or not
she is postterm, may carry iatrogenic risks, such as increased
rates of infection, hemorrhage, or other complications.
b. There is insufficient evidence to recommend one specific
time for labor induction. The common practices are to induce labor at 41 or 42 weeks in the presence of a favorable
(inducible) cervix. If the cervix is not favorable, management
alternatives include use of cervical ripening agents followed
by induction or expectant management with antenatal fetal
monitoring twice a week.
c. There is no direct, unbiased evidence that antepartal testing
reduces perinatal morbidity and mortality in prolonged gestation. Although the risk of antepartal stillbirth increases with
increasing gestational age, there is no evidence that allows
determination of the optimal time to initiate antepartal testing. However, common practice is to initiate the BPP or some
part of it such as the NST and AFV assessment to assess
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fetal condition and to identify oligohydramnios at 41 or
42 weeks of gestation. Testing is usually done twice weekly.
3 Nursing priorities are to encourage the woman to express her
feelings about having a prolonged pregnancy, to provide support, to teach her how to assess daily fetal movement (kick
counts), and to recognize signs of labor. She should also be encouraged to keep all appointments for fetal assessment tests and
cervical checks and to come to the labor and birth unit as soon
as her membranes rupture or labor begins.
4 Yes, the evidence objectively supports these conclusions, as there
is no one way to manage postterm pregnancy.
5 Yes. Alternative ways to stimulate labor have been studied (e.g.,
caster oil, stripping membranes, nipple stimulation, sexual intercourse). In general, there is a tradeoff between the effectiveness of induction agents in terms of achieving the labor and risks
of uterine tachysystole, hyperstimulation, and potential fetal
compromise.
References: ACOG, 2004b; Bowes & Thorp, 2004; Gilbert & Harmon,
2003; Myers et al., 2002; Resnik & Resnik, 2004; Simpson, 2002.
Resources
American College of Obstetricians and Gynecologists (ACOG)
409 12th St., SW
P.O. Box 96920
Washington, DC 20090-6920
800-762-2264
www.acog.org
Birthrites: Healing after Cesarean, Inc.
www.birthrites.org
C/SEC, Inc. (Cesarean/Support Education and Concern)
22 Forest Rd.
Framingham, MA 01701
508-877-8266
A Free Home for Moms on Bedrest
www.momsonbedrest.com
International Cesarean Awareness Network (ICAN)
1304 Kingsdale Ave.
Redondo Beach, CA 90278
310-542-6400
www.ican-online.org
Mothers of Supertwins (MOST)
P.O. Box 951
Brentwood, NY 11717
631-859-1110
www.mostonline.org
National Organization of Mothers of Twins Clubs, Inc.
(NOMOTC)
P.O. Box 438
Thompsons Station, TN 37179-0438
615-595-0936
www.nomotc.org
National Perinatal Association
3500 East Fletcher Ave., Suite 205
Tampa, FL 33613-4712
813-971-1008
www.nationalperinatal.org
Pregnancy Bedrest: A Reading Room to Help You Survive and
Thrive during Your Days of Waiting
Amy E. Tracy
445C E. Cheyenne Mtn. Blvd., #194
Colorado Springs, CO 80906
www.pregnancybedrest.com
Sidelines: High Risk Pregnancy Support Group
P.O. Box 1808
Laguna Beach, CA 92652
888-447-4754
www.sidelines.org
The Triplet Connection
P.O. Box 99571
Stockton, CA 95209
209-474-0885
www.tripletconnection.org
VBAC.com—A Woman-Centered Evidence Based Resource
Nicette Jukelevics
Center for Family
24050 Madison St., Suite 200
Torrance, CA 90505
310-375-3141
www.vbac.com
References
Abrahams, C., & Katz, M. (2002). A perspective on the diagnosis
of preterm labor. Journal of Perinatal and Neonatal Nursing, 16(1),
1-11.
Abrams., B., Minassian, D., & Pickett K. (2004). Maternal nutrition.
In R. Creasy, R. Resnik, & J. Iams (Eds.). Maternal-fetal medicine: Principles and practice (5th ed.). Philadelphia: Saunders.
Adler, C., & Zarchin, Y. (2002). The “Virtual Focus Group”: Using the
internet to reach pregnant women on home bed rest. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31(4), 418-427.
American College of Obstetricians and Gynecologists (ACOG). (2000).
Fetal macrosomia. ACOG Practice Bulletin no. 22. Washington, DC:
ACOG.
American College of Obstetricians and Gynecologists. (2003). New
ACOG opinion addresses elective cesarean controversy. News release,
October 31, 2003. Washington, DC: ACOG.
American College of Obstetricians and Gynecologists (ACOG).
(2004a). Vaginal birth after a previous cesarean delivery. ACOG Practice
Bulletin no. 54. Washington, DC: ACOG.
American College of Obstetricians and Gynecologists. (ACOG).
(2004b). Management of postterm pregnancy. ACOG Practice Bulletin no.
55. Washington, DC: ACOG.
American College of Obstetricians and Gynecologists (ACOG) &
American Academy of Pediatrics (AAP). (2002). Guidelines for perinatal
care (5th ed.). Washington, DC: ACOG.
Anotayanonth, S., Subhedar, N., Garner, P., Neilson, J., & Harigopal, S.
(2004). Betamimetics for inhibiting preterm labour. Cochrane Database Systematic Reviews, Issue 3, Article CD004352.
Association of Women’s Health, Obstetric and Neonatal Nurses
(AWHONN). (2000). Issue: Professional nursing support of laboring
women. Washington, DC: AWHONN.
769-818_CH24_Lowdermilk.qxd
12/1/05
3:04 PM
Page 817
CHAPTER
Baskett, T. (2002). Shoulder dystocia. Best Practices Research in Clinical
Obstetrics and Gynaecology, 16(10), 57-68.
Baxley, E., & Gobbo, R. (2004). Shoulder dystocia. American Family
Physician, 69(7), 1610, 1612-1613.
Berkman, N. et al. (2003). Tocolytic treatment for the management of
preterm labor: A review of the evidence. American Journal of Obstetrics and Gynecology, 188(6), 1648-1659.
Bernhardt, J., & Dorman, K. (2004). Pre-term birth risk assessment tools.
Exploring fetal fibronectin and cervical length for validating risk.
AWHONN Lifelines, 8(1), 38-44.
Bowes, W., & Thorp, J. (2004) Clinical aspects of normal and abnormal labor. In R. Creasy, R. Resnik, & J. Iams (Eds). Maternal-fetal medicine: Principles and practice (5th ed.). Philadelphia: Saunders.
Cesario, S. (2004). Reevaluation of Friedman’s labor curve: A pilot
study. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 33(6), 713722.
Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., &
Wenstrom, K. (2005). Williams’ obstetrics (22nd ed.). New York:
McGraw-Hill.
Curran, C. (2003). Intrapartum emergencies, Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32(6), 802-813.
Divon, M. (2002). Prolonged pregnancy. In S. Gabbe, J. Niebyl, &
J. Simpson (Eds.). Obstetrics: Normal and problem pregnancies (4th ed.).
New York: Churchill Livingstone.
Enkin, M. et al. (2000). A guide to effective care in pregnancy and childbirth
(3rd ed.). Oxford, NY: Oxford University Press.
Freda, M. (2003). Nursing’s contribution to the literature on preterm
labor and birth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32(5), 659-667.
Freda, M., & Patterson, E. (2001). Preterm birth: Prevention and nursing
management (2nd ed.). March of Dimes Nursing Module Series.
White Plains, NY: March of Dimes Birth Defects Foundation.
Friedman, E. (1989). Normal and dysfunctional labor. In W. Cohen et
al. (Eds.), Management of labor (2nd ed.). Rockville, MD: Aspen.
Fuchs, I., Henrich, W., Osthues, K., & Dudenhausen, J. (2004). Sonographic cervical length in singleton pregnancies with intact membranes presenting in threatened preterm labor. Ultrasound in Obstetrics and Gynecology, 24(5), 554-557.
Gamble, J., & Creedy, D. (2004). Content and processes of postpartum
counseling after a distressing birth experience: A review. Birth, 31(3),
213-218.
Gardner, P. (2003). Previous traumatic birth: An impetus for requested
cesarean birth. Journal of Perinatal and Neonatal Education, 12(1), 1-5.
Garite, T. (2004). Premature rupture of membranes. In R. Creasy,
R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Principles and practice (5th ed.). Philadelphia: Saunders.
Gennaro, S., & Hennessy, M. (2003). Physiological and psychological
stress: Impact on preterm birth. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 32(5), 669-675.
Gilbert, E., & Harmon, J. (2003). Manual of high risk pregnancy and delivery (3rd ed.). St. Louis: Mosby.
Goldberg, A., Greenberg, M., & Darney, P. (2001). Drug therapy: Misoprostol and pregnancy. New England Journal of Medicine, 344(1), 3847.
Goldenberg, R., Iams, J., Mercer, B., Meis, P., Moawad, A., Das, A.,
Copper, R., Johnson, F., & National Institute of Child Health and
Human Development Maternal-Fetal Medicine Units Network.
(2003). What we have learned about the predictors of preterm birth.
Seminars in Perinatology, 27(3), 636-643.
Gregory, K. (2000). Monitoring risk adjustment and strategies to decrease cesarean rates. Current Opinion in Obstetrics and Gynecology,
12(6), 481-486.
Hamilton, B., Martin, J., Sutton, P., & Centers for Disease Control and
Prevention, National Center for Health Statistics. (2004). Births: Preliminary data for 2003. National Vital Statistics Report, 23(9), 1-17.
24
Labor and Birth at Risk
817
Heaman, M., Sprague, A., & Stewart, P. (2001). Reducing the preterm
birth rate: A population health strategy. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 30(1), 20-29.
Hodnett, E. (2002). Caregiver support for women during childbirth.
Cochrane Database Systematic Reviews, Issue 1, Article CD000199.
Hodnett, E., Gates, S., Hofmeyr, G., & Sakala, C. (2003). Continuous
support for women during childbirth. Cochrane Database Systematic
Reviews, Issue 3, Article CD003766.
Hodnett, E., Lowe, N., Hannah, M., Willan, A., Stevens, B., &
Weston, J. (2002). Effectiveness of nurses as providers of birth support in North American hospitals. Journal of the American Medical Association, 288(11), 1373-1381.
Hofmeyr, G., & Hannah, M. (2003). Planned caesarean section for term
breech delivery (Cochrane Review). In The Cochrane Library, Issue 3,
2005. Chichester, UK: John Wiley & Sons.
Iams, J. (2002). Preterm birth. In S. Gabbe, J. Niebyl, & J. Simpson
(Eds.), Obstetrics: Normal and problem pregnancies (4th ed.). New York:
Churchill Livingstone.
Iams, J., & Creasy, R. (2004). Preterm labor and delivery. In R. Creasy,
R. Resnik, & J. Iams (Eds.). Maternal-fetal medicine: Principles and practice (5th ed.). Philadelphia: Saunders.
Lanni, S., & Seeds, J. (2002). Malpresentations. In S. Gabbe, J. Niebyl,
& J. Simpson (Eds.), Obstetrics: Normal and problem pregnancies (4th
ed.). New York: Churchill Livingstone.
Lehne, R. (2001). Pharmacology for nursing care. Philadelphia: Saunders.
Lieberman, E., Ernst, E., Rooks, J., Stapleton, S., & Flamm, B. (2004).
Results of the national study of vaginal birth after cesarean in birth
centers. Obstetrics & Gynecology, 104(5 Pt 1), 933-942.
Liu, S. et al. (2004). Recent trends in caesarean delivery rates and indications for caesarean delivery in Canada. Journal of Obstetrics and
Gynaecology of Canada, 26(8), 735-742.
Maloni, J. (1998). Antepartum bedrest: Case studies, research, and nursing
care. Washington, DC: AWHONN.
Maloni, J. (2000). The prevention of preterm birth: Research-based practice,
nursing interventions, and practice scenarios. Washington, DC:
AWHONN.
Maloni, J. (2002). Astronauts & pregnancy bed rest: What NASA
is teaching us about inactivity. AWHONN Lifelines, 6(4), 318323.
Maloni, J., & Kutil, R. (2000). Antepartum support group for women
hospitalized on bedrest. MCN American Journal of Maternal/Child
Nursing, 25(4), 204-210.
Maloni, J., & Park, S. (2005). Postpartum symptoms after antepartum
bedrest. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34(2),
163-171.
Maloni, J., Brezinski-Tomasi, J., & Johnson, L. (2001). Antepartum
bedrest: Effect upon the family. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 30(2), 165-173.
Maloni, J. et al. (1993). Physical and psychosocial side effects of antepartum bed rest. Nursing Research, 42(4), 197-203.
Martin, J. et al. (2003). Births: Final data for 2002. National Vital Statistics Report, 52(10), 1-113.
Massett, H., Greenup, M., Ryan, C., Staples, D., Green, N., &
Maibach, E. (2003). Public perceptions about prematurity: A national
survey. American Journal of Preventive Medicine, 24(2), 120-127.
Maupin R., Lyman, R., Fatsis, J, Prystowiski, E., Nguyen, A., Wright,
C., Kissinger, P., & Miller, J. (2004). Characteristics of women who
deliver with no prenatal care. Journal of Maternal Fetal Neonatal Medicine, 16(1), 45-50.
Mayberry, L., Wood, S., Strange, L., Lee, L., Heisler, D., NielsenSmith, K.. (2000). Second stage labor management: Promotion of evidencebased practice and a collaborative approach to patient care. Washington,
DC: AWHONN.
McCann, M. (2003). Days in waiting: A guide to surviving bedrest. St. Paul,
MN: deRuyter-Nelson Publications.
769-818_CH24_Lowdermilk.qxd
818
12/1/05
UNIT SEVEN
3:04 PM
Page 818
COMPLICATIONS OF CHILDBEARING
McFarlin, B. (2004). Elective cesarean birth: Issues and ethics of informed choice. Journal of Midwifery and Women’s Health, 49(5), 421429.
Miltner, R. (2002). More than support: Nursing interventions provided
to women in labor. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31(6), 753-761.
Moondragon Birthing Services. (2005). Moondragon’s pregnancy information: Coping with bedrest during pregnancy. Internet document available at www.moondragon.org/pregnancy/bedrestcope.html (accessed
May 1, 2005).
Moore, M. (2003). Preterm labor and birth: What have we learned in
the past two decades? Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 32(5), 638-649.
Moos, M. (2004). Understanding prematurity: Sorting fact from fiction.
AWHONN Lifelines, 8(1), 32-37.
Morrison, J., & Chauhan, S. (2003). Current status of home uterine activity monitoring. Clinics in Perinatology, 30(4), 757-801.
Myers, E. et al. (2002). Management of prolonged pregnancy. Evidence
Report/Technology Assessment no. 53. AHRQ Publication 02-E018.
Rockville, MD: Agency for Healthcare Research and Quality.
National Institutes of Health. (2000). Antenatal corticosteroids revisited.
Consensus Development Conference Statement. Maryland: NIH. Internet
document available at http://consensus.nih.gov. (Accessed 9/6/05).
Nelson, R. (2004). Premature births on the rise. American Journal of Nursing, 104(6), 23-24.
Nocon, J. (2000). Shoulder dystocia and macrosomia. In L. Kean,
P. Baker, & D. Edlestone (Eds.), Best practice in labor ward management.
Philadelphia: Saunders.
Norwitz, E., Robinson, J., & Repke, J. (2002). Labor and delivery. In
S. Gabbe, J. Niebyl, & J. Simpson (Eds.), Obstetrics: Normal and problem pregnancies (4th ed.). New York: Churchill Livingstone.
Ramsey, P., & Andrews, W. (2003). Biochemical predictors of preterm
labor: Fetal fibronectin and salivary estriol. Clinics in Perinatology,
30(4), 701-733.
Ramsey, P., Ramin, K., & Ramin, S. (2000). Labor induction. Current
Opinion Obstetrics and Gynecology, 12(6), 463-473.
Resnik, J., & Resnik, R. (2004). Post-term pregnancy. In R. Creasy,
R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Principles and practice, (5th ed.), Philadelphia: Saunders.
Rideout, S. (2005). Tocolytics of pre-term labor: What nurses need to
know. AWHONN Lifelines, 9(1), 56-61.
Ridley, R., Davis, P., Bright, J., & Sinclair, D. (2002). What influences
a woman to choose vaginal birth after cesarean? Journal of Obstetric,
Gynecologic, and Neonatal Nursing, 31(6), 665-672.
Ruchata, P., Metheby, N., Essenpreis, H., & Borcherding, K. (2002).
Current practices in oxytocin dilution and fluid administration for
induction of labor. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31(5), 545-550.
Schaffir, J. (2002). Survey of folk beliefs about induction of labor. Birth,
29(1), 47-51.
Simkin, P., & Ancheta, R. (2000). The labor progress handbook. Malden,
MA: Blackwell Science.
Simpson, K. (2002). Cervical ripening and induction and augmentation of
labor (2nd ed.). Washington, DC: AWHONN.
Simpson, K., & Atterbury, J. (2003). Trends and issues in labor induction in the United States: Implications for clinical practice. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32(6), 767-779.
Simpson, K., & Knox, G. (2001). Fundal pressure during second stage
of labor. MCN American Journal of Maternal Child Nursing, 26(6), 6470.
Society of Obstetricians and Gynaecologists of Canada (SOGC).
(2004). News. C-sections on demand—SOGC’s position. Birth,
31(2),154.
Sosa, C., Athalbe, F., Belzian, J., & Bergel, E. (2004). Bed rest in singleton pregnancies for preventing preterm birth. Cochrane Database
of Systematic Reviews, Issue 1, Article CD003581.
Tiedje, L. (2003). Psychosocial pathways to prematurity: Changing our
thinking toward a lifecourse and community approach. Journal of
Obstetric, Gynecologic, and Neonatal Nursing, 32(5), 650-658.
Tracy, A. (2001). The pregnancy bed rest book: A survival guide for expectant
mothers and their families. New York: Berkley Publishing Group.
Weiss, M., Saks, N., & Harris, S. (2002). Resolving the uncertainty of
preterm symptoms: Women’s experiences with the onset of preterm
labor. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31(1),
66-76.
Weitz, B. (2001). Premature rupture of the fetal membranes: An update for advanced practice nurses. MCN American Journal of Maternal Child Nursing, 26(2), 86-92.
Williams, D. (2005). The top 10 reasons elective cesarean section should
be on the decline. AWHONN Lifelines, 9(1), 23-24.
Witcher, P. (2002). Treatment of preterm labor. Journal of Perinatal and
Neonatal Nursing, 16(1), 25-46.