Nursing Management of Labor and Birth at Risk

Dystocia

Abnormal or difficult labor Vast number of maternal and fetal factors Problems with powers: hypertonic uterine

dysfunction, hypotonic uterine dysfunction, precipitous labor

Problems with passenger: occiput posterior position, breech presentation, multifetal pregnancy, macrosomia and CPD, structural abnormalities

Problems with the passageway: pelvic contraction, obstructions in maternal birth canal

Problems with psyche: psychological distress

Dystocia (cont’d) Nursing Assessment

History of risk factors Vital signs Uterine contractions Fetal heart rate, fetal position

Nursing Management Promoting labor progress Providing physical and emotional comfort Promoting empowerment

Preterm Labor

Regular uterine contractions with cervical effacement and dilation between 20 and 37 weeks’ gestation

One of most common obstetric complications Therapeutic management

Risk prediction Tocolytic drugs: magnesium sulfate,

terbutaline, indomethacin, nifedipine Corticosteroids Antibiotic prophylaxis for women with group B

streptococcus

Preterm Labor (cont’d) Nursing Assessment

Risk factors Subtle signs Contraction pattern (4 contractions every

20 minutes or 8 contractions in 1 hour) Laboratory and diagnostic testing: fetal

fibronectin, cervical length via transvaginal ultrasound, salivary estriol, home uterine activity monitoring

Preterm Labor (cont’d)

Nursing Management Tocolytic administration Client education Psychological support

Question

Is the following statement True or False?

Psychological stress in the woman can contribute to dystocia.

Answer

True.

Emotions such as fear, anxiety, helplessness, being alone, and weariness can lead to psychological stress, indirectly causing dystocia.

Postterm Labor

Pregnancy continuing past end of 42 weeks’ gestation

Unknown etiology Maternal and fetal risks Nursing Assessment: estimated date of birth; daily

fetal movement counts, nonstress tests twice weekly, amniotic fluid analysis, weekly cervical examinations

Nursing Management: fetal surveillance; decision for labor induction; support; education, intrapartal care

Labor Induction and Augmentation

Induction: stimulating contractions via medical or surgical means; Augmentation: enhancing ineffective contractions after labor has begun

Indications Therapeutic management

Cervical ripening (Bishop’s score): nonpharmacologic methods; mechanical methods; surgical methods; pharmacologic agents

Oxytocin

Labor Induction and Augmentation (cont’d)

Nursing Assessment Relative indications; gestational age

determination Fetal status; maternal status; Bishop’s

score Nursing Management

Explanations Oxytocin administration Pain relief and support

Question

Is the following statement True or False?

Oxytocin is an important agent used to ripen the cervix for labor induction.

Answer

False.

Oxytocin is used to induce or augment labor once the cervix is ripe.

Intrauterine Fetal Demise

Numerous causes Devastating effects on family and staff Nursing Assessment

Inability to obtain fetal heart sounds Ultrasound to confirm absence of fetal

activity Labor induction

Nursing Management Assistance with grieving process Referrals

Umbilical Cord Prolapse

Obstetric emergency Pathophysiology: partial or total occlusion

of cord with rapid fetal deterioration Nursing Assessment

Prevention; risk factors Continuous assessment of client and fetus

Nursing Management Prompt recognition Measures to relieve compression

Placental Abruption Obstetric emergency involving premature

separation Risk factors Management dependent on gestational age,

extent of hemorrhage and maternal-fetal oxygenation perfusion

Maintenance of maternal cardiovascular status Prompt delivery of fetus Cesarean birth if fetus still alive; vaginal birth if

fetal demise

Uterine Rupture Obstetric emergency; onset marked by

sudden fetal bradycardia Nursing Assessment

Risk factors Onset of sudden fetal distress; other signs

Nursing Management Preparation for urgent cesarean birth Continuous maternal and fetal monitoring

Amniotic Fluid Embolism Obstetric emergency Sudden onset of hypotension, hypoxia, and

coagulopathy due to breakage in barrier between maternal circulation and amniotic fluid

Nursing Assessment: difficulty breathing, hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony with subsequent hemorrhage, ARDS, cardiac arrest

Nursing Management: supportive measures to maintain oxygenation and hemodynamic function and to correct coagulopathy; critical care monitoring

Question

Which of the following assessment findings would lead the nurse to suspect an amniotic fluid embolism?

A.Respiratory distress B.HypertensionC.Acute abdominal pain D.Sudden fetal distress

Answer

A.

Amniotic fluid embolism should be suspected in any pregnant woman with an acute onset of respiratory distress and hypotension. Sudden fetal distress and acute abdominal pain are associated with uterine rupture.

Amnioinfusion Indications

Severe variable decelerations due to cord compression

Oligohydramnios due to placental insufficiency Postmaturity or rupture of membranes Preterm labor with premature rupture of

membranes Thick meconium fluid

Nursing management: teaching, maternal and fetal assessment, preparation for possible cesarean birth

Forceps- or Vacuum-Assisted Birth Application of traction to fetal head Indications: Prolonged second stage of labor,

nonreassuring FHR pattern, failure of presenting part to fully rotate and descend, limited sensation or inability to push effectively, presumed fetal jeopardy or fetal distress, maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, infection

Risk of tissue trauma to mother and newborn. Prevention as key

Cesarean Birth

Classic or low transverse incision Major surgical procedure with

accompanying risks Nursing Assessment: history and

physical examination for maternal and fetal indications

Nursing Management Pre-operative care Post-operative care

Question

Is the following statement True or False?

An amnioinfusion is appropriate for a pregnant woman experiencing a prolonged second stage of labor.

AnswerFalse.

Amnioinfusion is indicated for severe variable decelerations due to cord compression, oligohydramnios due to placental insufficiency, postmaturity or rupture of membranes, preterm labor with premature rupture of membranes, and thick meconium fluid. A forceps- or vacuum-assisted birth would be indicated for a prolonged second stage of labor.

Vaginal Birth After Cesarean (VBAC) Controversy related to risk of uterine rupture

and hemorrhage Contraindications Special areas of focus: consent,

documentation, surveillance, and readiness for emergency

Nurses as advocates for clients; expertise in reading fetal monitoring tracings to identify nonreassuring pattern and instituting measures for emergency delivery