CHILDBIRTH AT RISK Chapter 21

PSYCHOLOGICAL DISORDERS: BEHAVIORS IN LABOR Depression: decreased ability to concentrate, or process information; feeling overwhelmed and hopeless Bipolar disorder: may be depressed or hyper excited Anxiety disorder: chest pain SOB, faintness, fear Clinical therapy goals: decrease anxiety, maintain orientation to reality, promote optimal functioning in labor

HYPERTONIC LABOR DYSTOCIA Characteristics: increased contraction frequency and uterine resting tone; prolonged latent phase Implications: prolonged labor and discomfort; reduced uteroplacental exchange resulting inn nonreassuring fetal status Prolonged pressure on fetal head resulting in molding, caput succedaneum and cephalohematoma

Clinical therapy for Hypertonic labor Bed rest and relaxation measures Pharmacologic sedation Oxytocin amniotomy

HYPOTONIC LABOR (fewer tan 3 contractions in 10 min) Usually in active phase after labor already established Clinical therapy: oxytocin, amniotomy, IV fluids Nursing Plan: Assess amniotic fluid for meconium Monitor VS, FHT, I&O, minimize SVE, assess for signs of infection Ambulate, position changes, hydrotherapy relaxation exercises

PRECIPITOUS LABOR (less than 3 hours) Contributing factors: multiparity, large pelvis, previous precipitous labor, small fetus in a favorable position, strong contractions, uterine hyper stimulation from excess pitocin Implications: loss of coping ability, laceration of cervix, vagina, perineum, postpartum uterine atony, hemorrhage, fetal stress or hypoxia from intense uterine ctx. Cerebral trauma from rapid descent, pneumothorax from rapid descent

NURSING PLAN FOR PRECIPITOUS LABOR Anticipate r/t risk factors (be prepared) Frequent monitoring and assess for accelerated labor progress (intense ctx with little uterine relaxation), constant nursing attendance Prepare for delivery early; keep Dr. informed Institute supportive measures for hyper stimulation: d/c pitocin, side-lying, O2

POSTTERM (more than 42 weeks gestation) Implications: Probable labor induction Risk for large baby Decreased placental perfusion Oligohydramnios Meconium aspiration

Nursing plan for Postterm Pregnancy Teach fetal kick counts antenatally Ongoing FHR assessment for signs of cord compression in labor Take corrective action for cord compression due to oligohydramnios: position change, O2, amnioinfusion Carefully monitor labor progress Provide emotional support

FETAL MALPOSITON Persistent occiput-posterior (OP) Fetal malpresentation: Brow Face Breech Transverse Compound (two presenting parts)

MACROSOMIA (infant weight of 4000g or 8#13oz) Predisposing factors: male gender, offspring of large parents, maternal diabetes, prolonged gestation, previous large infant, grand multiparity. Implications: dysfuntional labor, soft tissue laceration during birth, PP hemorrhage, CPD with subsequent cesarean, meconium aspiration, shoulder dystocia, brachial plexus injury, fractured clavicle, asphyxia

NURSING PLAN FOR MACROSOMIC INFANT Continuous EFM; assess for fetal stress (decels) Assess for labor dystocia Anticipate and assist with emergency measures during birth as needed such as McRoberts maneuver, suprapubic pressure, emergency CS Anticipate uterine atony postpartum Assess newborn for birth trauma

MULTIPLE GESTATION (TWINS AND MORE) Predisposing factors: infertility treatment, advanced maternal age, African American ethnicity, multiparity, tall, overweight women Early indicators: two gestational sacs on early US, fundal ht greater than expected, auscultation of two or more heart rates differing by more than 10 beats, elevated hCG with severe nausea and vomiting, elevated alph-fetoprotein

Implications of multiple gestation Increased maternal discomfort Preeclampsia Preterm labor Placenta previa Abnormal fetal presentation Dysfunctional labor Ten times greater perinatal mortality Increased IUGR, fetal anomalies, cerebral palsy, and sequelae of prematurity

NURSING PLAN Prenatal: educate on lifestyle modifications; nutrition: 4000 cal daily, 135 g protein, 40-50lb wt gn increased prenatal visits: weekly NST at 30 wks, weekly BPP, educate on danger signs

Nursing Plan: Continuous EFM 18 g IV catheter Double setup for delivery of newborn Alert additional staff for help with birth and newborn care Be prepared for CS

FETAL DISTRESS Common causes: cord compression, uteroplacental insufficiency, placental abnormalities, preexisting maternal or fetal disease Fetal implications: chronic hypoxia, permanent organ damage, potential emergent CS

Institute Intrauterine Resuscitation measures: Common initial signs of fetal stress: meconium-stained amniotic fluid, persistent late decels, persistent severe variable decels Institute Intrauterine Resuscitation measures: Correct maternal hypotension and enhance uteroplacental blood flow Change position that improves FHR, Increase rate of IV O2 via face mask Decrease uterine activity: stop pitocin, adm tocolytic Perform vaginal exam (prolapsed cord?)

ABRUPTIO PLACENTAE (premature separation of placenta) Contributing factors: hydramnios, twins, smoking, street drugs, trauma Significant symptoms: pain, uterine irritability, and a firm, hard abdomen Types: Marginal Central Complete

Maternal implications: intrapartum hemorrhage, DIC, ruptured uterus, fatal hemorrhagic shock Fetal-neonatal implications: sequelae of prematurity, hypoxia, anemia, brain damage, fetal demise

Nursing plan Maintain two large bore IV sites Monitor frequently Monitor for signs of DIC Monitor I&O hourly Measure abdominal girth hourly as well as vital signs q 15 minutes Prepare for CS and neonatal resuscitation

Placenta Previa (placenta implanted in lower uterine segment Categories : total, partial, marginal, low-lying Most accurate diagnostic sign is painless, bright-red vaginal bleeding. Implications: changes in FHR, meconium staining, fetal hypoxia, cesarean birth, neonatal anemia

NURSING PLAN No vaginal exams! Assess blood loss, pain, uterine contractions Continuous external monitoring Monitor VS and I&O often Maintain IV access Provide emotional support Promote neonatal adaptation: resuscitate as needed, evaluate H/H, administer oxygen and blood as needed

UMBILICAL CORD PROLAPSE (cord precedes the fetal presenting part and gets trapped) Implications: extreme maternal emotional stress, CS, hypoxia, brain damage, fetal death Nursing Plan: perform a vaginal exam to establish engagement or rule out prolapse, Maintain hand in vagina to relieve cord compression, assist to knee-chest position, prepare for stat CS.

Amniotic Fluid Embolism S&S: dyspnea, cyanosis, frothy sputum, chest pain, tachycardia, hypotension, mental confusion, massive hemorrhage Nursing Plan: summon emergency team, O2, large bore IV, CPR as needed, prepare for CS birth, administer blood

HYDRAMNIOS Greater than 2000ml of amniotic fluid Cause unknown but major fetal anomalies are present in 20% Implications for Mother: shortness of breath, edema, uterine dysfunction, abruptio placenta, PP hemorrhage Implications for fetus: malformations, preterm birth, increases mortality rate, prolapsed cord, malpresentation

OLIGOHYDRAMNIOS Amniotic fluid reduced or concentrated to less than 50% of normal or less than 500 ml at term Found in postmaturity , and associated primarily with fetal renal defects or placental insufficiency Implications: dysfunctional labor with slow progress Umbilical cord compression, head compression May need amnioinfusion during labor

CEPHALOPELVIC DISPROPORTION (CPD) A contracture or narrow diameter in birth passage especially if fetus is larger than the maternal pelvic diameters. Implications: Maternal: prolonged labor, arrest of descent, uterine rupture, forceps-assisted birth with trauma Implications: Fetal: cord prolapse, excessive molding of head, birth trauma to skull and CNS

Nursing Plan for CPD Assess cervical change and fetal descent frequently Continuously monitor FHT Be alert for signs of fetal stress Assist with optimal positioning during labor such as squatting, hands and knees

Complications of 3rd and 4th stages of Labor Retained Placenta: beyond 30 minutes after birth Lacerations: first, second, third (extends through the perineal body and involves the anal sphincter and fourth (extends through the rectal mucosa to the lumen of the rectum. Placenta accreta: the chorionic villi attach directly to the myometrium of the uterus

Fetal Death

REVIEW Dystocia/hypotonic – difficult, often prolonged labor caused by dysfunctional or uncoordinated uterine activity Irregular in timing, strength or both and arrest cervical change Pharmocologic sedation will frequently stop these contractions If rest doesn’t improve the pattern, labor stimulation with pitocin may be used if CPD ruled out

Precipitous birth is not the same as precipitous labor Precipitous birth is not the same as precipitous labor. Precipitous labor is simply a rapid labor followed by anticipated birth., Precipitous birth is unexpected, sudden and often unattended. There are both maternal and fetal risks with precipitous labor

Implications of postterm primarily stem from decreasing placental function and concerns abut fetal size and well-being Meconium is more common in postterm pregnancies, possibly due to fetal maturity, or stress related to suboptimal placental functioning Careful assessment of labor progress is warranted due to the risk of CPD from macrosomia

MALPOSITION Occiput posterior is the most common fetal malposition During labor, 90 to 95% of OP fetuses rotate to OA position Maternal position such as hands and knees may facilitate fetal rotation and relieve back pain

Malpresentations Brow, face, breech shoulder and compound Many brow presentations convert to occipital or face with fetal descent Reassure the couple that the edema and bruising are temporary and will be markedly improved in 3-4 days, though complete resolution may take several weeks.

The nurse is frequently the first to recognize breech presentation through Leopold’s maneuvers and vaginal exam. Footling breech, nurse must be alert for prolapsed cord. The danger is greater if there is a small fetus and membranes are ruptured If transverse lie persists at term, external cephalic version may be useful

Macrosomia Primary risks are CPD and shoulder dystocia Dysfunctional labor or lack of fetal descent could indicate CPD Birth trauma associated with this are: Erb’s palsy Fractured clavicle cephalohematoma

More than one fetus Clinical monitoring usually begins in 3rd trimester and continues until nonreassuring findings are obtained or birth occurs

Abruptio Placentae Separation of normally implanted placenta Occurs more frequently in pregnancies with hypertension and cocaine abuse. Also smoking and alcohol ingestion are contributing factors Clotting disorders (DIC) result when uterine wall damage and retroplacental clotting from central separation trigger release of a large amount of thromboplastin into maternal circulation

If separation is mild and pregnancy near term, labor induction may be feasible Signs are painful, board like distended abdomen and uterine irritability

Placenta Previa Signs are painless bleeding. Abdomen is soft Management based on gestational age at first bleeding episode and the amount of bleeding No vaginal exams should be done by nurse Preterm can usually be managed with bed rest with bathroom privileges only as long as there is no bleeding, pain and uterine contractions until fetus is mature.

Umbilical cord Prolapse Compresses the blood vessels to and from the fetus. Labor ctx further compress the cord A drop in fetal heart rate accompanied by variable decelerations is consistent with prolapse cord. And a vaginal exam is the best way to confirm. The number one priority is to relieve compression to allow blood flow to reach fetus. A c-section is imminent.

Polyhydramnios Occurs in 10 to 20% of pregnant diabetics Major fetal anomalies are present in 20% of cases Uterine over distention may result in labor dysfunction and postpartum hemorrhage Rupture of membranes increases risk of cord prolapse An abnormally taut abdomen with difficulty palpating the fetus may be suspicious for hydramnios