Nursing Care of Women with Complications During Labor and Birth

Nursing Care of Women with Complications During Labor and Birth
Chapter 8 Nursing Care of Women with Complications During Labor and Birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Obstetric Procedures (p. 174)
Amnioinfusion Oligohydramnios- low amniotic fluid Umbilical cord compression from low fluid Reduction of recurrent variable decelerations Dilution of meconium-stained amniotic fluid Replaces the “cushion” for the umbilical cord and relieves the variable decelerations An amnioinfusion is the instillation of fluids into the uterus by means of an intrauterine-pressure catheter (IUPC). Discuss the nursing care required for the patient undergoing an amnioinfusion. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Induction or Augmentation of Labor (p. 174)
Induction is the initiation of labor before it begins naturally Augmentation is the stimulation of contractions after they have begun naturally Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Bishop Scoring System (p. 175)
Evaluates the cervical response to induction procedures A high score (above 6) is predictive of successful labor induction because the cervix has ripened or softened in preparation for labor Health care providers can use Bishop’s score to determine a patient’s potential for successful induction. What are the parameters included in Bishop’s scoring system? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Indications for Labor Induction (p. 175)
Gestational hypertension Ruptured membranes without spontaneous onset of labor Infection within the uterus Medical problems in the woman that worsen during pregnancy Fetal problems such as slowed growth, prolonged pregnancy, or incompatibility between fetal and maternal blood types Placental insufficiency Fetal death Discuss the underlying reasons that these factors indicate labor induction. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Contraindications to Labor Induction (p. 175)
Placenta previa Umbilical cord prolapse Abnormal fetal presentation High station of the fetus Active herpes infection in the birth canal Abnormal size or structure of the mother’s pelvis Previous classic cesarean incision Explain why these are contraindications for inducing labor. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Methods to Stimulate Contractions (p. 175)
Cervical ripening Prostaglandin in a gel or vaginal insert is applied before labor induction to soften the cervix Laminaria is an alternative to cervical ripening by swelling inside the cervix Oxytocin induction and the augmentation of labor Used to initiate or stimulate contractions Most commonly used method Cervical softening assists with efforts to induce labor. Oxytocin does not have cervical ripening properties. Review the steps taken to administer prostaglandin and laminaria. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Oxytocin used to induce labor without a “ripe cervix” can result in the need for a cesarean section
Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Question 1 Cervical ripening with prostaglandin gel is considered a method of labor induction. True False Answer: 1 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Methods to Stimulate Contractions (p. 175)
Prostaglandin E1: Cytotec (Misoprostol) Administer PO (buccal/sublingual) or intravaginally More effective in achieving vaginal delivery within 24 hours Adverse effect: uterine tachysystole (hyperstimulation) Prostaglandin E2: Prepidil or Cervidil Administer intravaginally, sustained release Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Preparing the Woman for Labor Augmentation (p. 175)
Explain procedure to woman Obtain baseline vital signs and fetal heart rate Ensure IV line is placed Remains in bed for up to 2 hours Oxytocin induction can start 6-12 hours after vaginal insert has been removed Assess for signs of uterine tachysystole Why is it important to obtain baseline vital signs and fetal heart rates? Why is an IV line needed? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Dilating the Cervix (p. 176) pharmalogic or mechanical means
RU486 (Mifepristone): steroid receptor agonist use for early pregnancy termination Stripping amniotic membranes Hydroscopic dilators Transcervical balloon dilators Extra-amniotic saline infusion RU486 is used in conjunction with other medications to augment labor. Stripping membranes involves separating the chorioamniotic membranes from the wall of the lower uterine segment. Hydroscopic dilators: use of laminaria that once inserted into the lower uterine segment, stimulates the release of prostaglandins. The laminaria swell inside the cervix. Transcervical balloon dilators insert a 16 Fr catheter 30 mL balloon inserted through the cervix and slowly inflated. The mechanical pressure dilates the cervix. Extra-amniotic saline infusion is sometimes used with the balloon dilator. Evidence-based studies do not support the efficacy of this practice. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Obstetric Procedures (cont.) (p. 176)
Amniotomy The artificial rupture of membranes Done to stimulate or enhance contractions Commits the woman to delivery Stimulates prostaglandin secretion Complications Prolapse of the umbilical cord Infection Abruptio placentae –separation of the placenta from fetus before birth Prior to an amniotomy, a series of assessments must be completed. What are the needed assessments? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Complications Associated with Amniotomy (p. 176)
Prolapsed umbilical cord – may slip down with the gush of amniotic fluid Infection – membrane no longer blocks organisms from entering the uterus Abruptio placentae – separation of the placenta before birth What are the signs and symptoms of each of the identified complications? Explain why the rupture of membranes could yield these results. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Tip (p. 176) Observe for wet underpads and linens after the membranes rupture. Change them as often as needed to keep the woman relatively dry and to reduce the risk for infection or skin breakdown. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Obstetric Procedures (cont.) (p. 176)
Observe for complications postamniotomy Fetal heart rate outside normal range ( beats/min) suggests umbilical cord prolapse Observe color, odor, amount, and character of amniotic fluid Woman’s temperature 38° C (100.4° F) or higher is suggestive of infection Green fluid may indicate that the fetus has passed a meconium stool Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Question 2 You are assessing characteristics of amniotic fluid postamniotomy. You observe the color of the fluid to be green-tinged. This can indicate the potential for: preterm delivery. vaginal infection. cervical trauma. fetal distress. Answer: 4 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nonpharmacological Methods to Stimulate Contractions (p. 177)
Walking Stimulates contractions Eases pressure of the fetus on the mother’s back Adds gravity to the downward force of contraction Nipple stimulation of labor Causes the pituitary gland to secrete natural oxytocin Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Complications of Augmentation of Labor (p. 177)
Most common is related to Overstimulation of contractions Fetal compromise – blood flow to the placenta is reduced if contractions are excessive Uterine rupture – tear in the uterine wall Water intoxication from oxytocin Inhibits excretion of urine and promotes fluid retention Nursing action: stop oxytocin infusion, increase non medicated IV solution, change woman’s position, give 02 8 to 10L/min with facemask View the nursing assessments that must accompany oxytocin administration. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Version (p. 178) A method used to change fetal presentation
Two methods External—usually performed at 37 weeks, but before onset of labor Internal—emergent, during labor The ideal position for the fetus in the period preceding the onset of labor is vertex. When the fetus is not in that position, the health care provider might be able to manually change the position of the fetus. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Risks and Contraindications of Version (p. 178)
Disproportion between mother’s pelvis and fetal size Abnormal uterine or pelvic size or shape Abnormal placental placement Previous cesarean birth with vertical uterine incision Active herpes virus infection Inadequate amniotic fluid Poor placental function Multifetal gestation Fetus can become entangled in umbilical cord The listed conditions are not appropriate for a version. Discuss the reasons for their being excluded. Review the risks that could be associated with a version. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Episiotomy and Lacerations (p. 179)
Episiotomy—controlled surgical enlargement of the vaginal opening during birth Lacerations—uncontrolled tear of the tissues that results in a jagged wound An episiotomy can be performed at the time of delivery to assist in the birth of the baby. Compare and contrast episiotomies and lacerations. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Perineal Lacerations (p. 179)
First degree—superficial vaginal mucosa or perineal skin Second degree—involves vaginal mucosa, perineal skin, and deeper tissues of the perineum Third degree—same as second degree, plus involves anal sphincter Fourth degree—extends through the anal sphincter into the rectal mucosa Episiotomies and lacerations are classified by the tissue involved. Discuss care of perineal lacerations. Women who have experienced a third- or fourth-degree laceration are not given anything via the rectum. This includes enemas and suppositories. What nursing interventions might be needed for these patients to prevent constipation? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Indications for an Episiotomy (p. 179)
Better control over where and how much the vaginal opening is enlarged An opening with a clean edge rather than the ragged opening of a tear Note: Perineal massage and stretching exercises before labor may be an alternative to an episiotomy Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Forceps Extraction (p. 180)
Provides traction and rotation of the fetal head when the mother’s pushing efforts are insufficient to accomplish a safe delivery Forceps may also help the physician extract the fetal head through the incision during a cesarean birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Forceps to Assist the Birth of the Fetal Head (p. 180)

Vacuum Extraction Birth (p. 180)
Uses suction applied to the fetal head so the physician can assist the mother’s expulsive efforts Used only with occiput presentation Forceps or vacuum extraction is used at the end of the second stage of labor. Why would forceps or vacuum extraction be utilized? Discuss additional criteria that must be present for the use of forceps or vacuum extraction. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Vacuum Extraction Birth (cont.) (p. 180)

Risks of Forceps or Vacuum Extraction (pp. 180-181)
Trauma to maternal or fetal tissues Mother may have a laceration or hematoma in her vagina Infant may have bruising, facial or scalp lacerations or abrasions, cephalohematoma, or intracranial hemorrhage Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Cesarean Birth (p. 181) The surgical delivery of the fetus through incisions in the mother’s abdomen and uterus Cesarean births account for more than 32% of all deliveries in the United States. Why are there a growing number of cesarean births? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Indications for Cesarean Birth (p. 181)
Abnormal labor Inability of the fetus to pass through the mother’s pelvis Maternal conditions such as GH or DM Active maternal herpes virus Previous surgery on the uterus Fetal compromise Placenta previa or abruptio placentae Discuss potential contraindications to cesarean birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Risks of Cesarean Birth (p. 181)
Mother Anesthesia Respiratory complications Hemorrhage Blood clots Injury to urinary tract Delayed intestinal peristalsis Infection What are the risks to the fetus in a cesarean birth? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Risks of Cesarean Birth (p. 181)
Newborn Inadvertent preterm birth Respiratory problems because delayed absorption of lung fluid Injury, such as laceration or bruising Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Preparation for Cesarean Birth (p. 182)
Clinical lab studies to identify anemia and blood-clotting abnormalities CBC, coagulation studies, blood typing Baseline vital signs, including fetal heart rate Position woman for comfort IV line Foley catheter inserted Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Types of Incisions (p. 182) Skin Uterine
Vertical allows more room for a large fetus Transverse (a.k.a. Pfannenstiel) Uterine Low transverse: not likely to rupture during another birth; VBAC possible with this type Low vertical: minimal blood loss; more likely to rupture during another birth Classic: rarely used; more blood loss; most likely to rupture during another pregnancy It should be noted that the type of incision on the external abdomen is not an indicator of the type of surgical incision on the uterus. Which factors will be taken into consideration by the surgeon when determining what type of surgical incision to use for a cesarean section? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Sequence of Events in Cesarean Birth (p. 183)
There is a series of events which will take place during a cesarean section: Administering anesthetic Cleaning and draping the expectant mother Making skin incision Making uterine incision Rupturing membranes (if not yet completed) Removing the fetal head or buttocks Suctioning the mouth and nose Clamping the cord Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Question 3 At what point of a cesarean section delivery would the woman’s support person enter the room? With the patient During the abdominal preparation After the incision has been made After the baby has been delivered Answer: 1 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Cesarean Section Birth (p. 183)
Woman may need more emotional support Emotional care of the partner and family is essential Mothers who undergo a cesarean birth might experience feelings of discontent about their inability to deliver vaginally. Identify behaviors that could signal this occurrence. What nursing interventions could assist the mother in coming to terms with these feelings? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care in the Recovery Room (p. 183)
Vital signs to identify hemorrhage or shock IV site and rate of solution flow Fundus for firmness, height, and midline position Dressing for drainage Lochia for quantity, color, and presence of clots Urine output from the indwelling catheter After surgery, the patient will recover in the postanesthesia care unit (PACU). The nurse will be required to perform the assessments identified on the slide. What are assessment findings that could indicate the onset of complications? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Safety Alert (p. 183) Although assessing the uterus after cesarean birth causes discomfort, it is important to do so regularly The woman may have a relaxed uterus that causes excessive blood loss, regardless of how she delivered her child Massage is not needed if the fundus is already firm Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Abnormal Labor (p. 183) Called dysfunctional labor Dystocia
Does not progress Dystocia Difficult labor The normal progression of labor involves cervical dilation, effacement, and fetal descent. When the 4 Ps of the labor process do not progress appropriately, the labor could be classified as abnormal. What are the 4 Ps of the labor process? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Risk Factors for Dysfunctional Labor (p. 184)
Advanced maternal age Obesity Overdistention of uterus Hydramnios or multifetal pregnancy Abnormal presentation Cephalopelvic disproportion (CPD) Overstimulation of the uterus Maternal fatigue, dehydration, fear Lack of analgesic assistance The conditions listed on the are associated with dysfunctional labor. Identify the elements in these situations that will contribute to the development of a dysfunctional labor pattern. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Problems with the Powers of Labor (p. 185)
Hypertonic Increased muscle tone Usually occurs during the latent phase of labor Characterized by contractions that are frequent, cramplike, and poorly coordinated Painful but nonproductive Uterus is tense, even between contractions, leads to reduced blood flow to the placenta Contraction patterns that are hypertonic, as well as hypotonic, could be associated with a dysfunctional labor pattern. Review nursing/medical interventions that might be implemented to manage these conditions. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Problems with the Powers of Labor (cont.) (p. 185)
Hypotonic Decreased muscle tone Labor begins normally, but diminishes during active phase More likely to occur if uterus is overdistended Stretches the muscle fibers and reduces their ability to contract effectively Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Ineffective Maternal Pushing (p. 187)
Woman may not understand which technique to use or fears tearing her perineal tissues Epidural or subarachnoid blocks may depress or eliminate the natural urge to push An exhausted woman may be unable to gather enough energy to push When providing care to a patient who is unable to effectively push, the nurse will need to assist as needed. What nursing interventions could be employed? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Problems with the Fetus (p. 187)
The passenger, or the fetus, might cause the labor’s progression to be dysfunctional. These problems include size, presentation, or positioning. Other factors might include multifetal pregnancies and birth defects. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Fetal Size (p. 187) Macrosomia—large fetus; weighs more than 4000 g (8.8 pounds) May not fit through birth canal Can contribute to hypotonic labor dysfunction Identify populations that might be at an increased risk for a macrosomic fetus. Review the nursing assessments that should be implemented to monitor for potential complications in the mother and newborn after the delivery of a macrosomic infant. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Shoulder Dystocia (p. 189) Usually occurs when fetus is too large
Is an emergency Fetal chest cannot expand and the fetus needs to be able to breathe After delivery, mother and infant need to be assessed for injuries Mother may have torn perineal tissue More at risk for uterine atony and postpartum hemorrhage Uterus does not contract well after birth Infant may have fractured clavicle Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Question 4 A woman in labor is experiencing dystocia. One possible cause for this is: the cervix has reached full dilation. the umbilical cord has prolapsed. excessive size of the fetus. extreme maternal fatigue. Answer: 4 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Abnormal Presentations (p. 189)
Does not pass easily Interferes with most efficient mechanisms of labor Can cause cord compression May require external version Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Abnormal Positions (p. 189)
Common cause is a fetus that remains in a persistent occiput posterior position Labor may last longer Woman may experience intense and poorly relieved back and leg pain May require forceps-assisted delivery Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care for Abnormal Fetal Presentation or Positions (p. 189)
Encourage woman to assume positions that favor fetal rotation and descent and reduce back pain Sitting, kneeling, or standing while leaning forward Rocking the pelvis back and forth while on hands and knees (encourages rotation) Side-lying Squatting (in second stage of labor) Lunging by placing one foot in a chair with the foot and knee pointed to that side Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Multifetal Pregnancy (p. 190)
May cause dysfunctional labor Uterine overdistention contributes to poor contraction quality Abnormal presentation or position of one or more fetuses interferes with labor mechanisms Often one fetus is delivered as cephalic and the second as breech, unless a version is done The nursing care for a multifetal pregnancy during the labor process is more complex than that for a single fetus. What are the monitoring requirements for the fetuses? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

The Psyche (p. 191) Most common factors that can prolong labor
Lack of analgesic control of excessive pain Absence of a support person or coach Immobility and restriction to bed Lack of ability to carry out cultural traditions Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Increased Anxiety (p. 191) Causes hormones to be released
Epinephrine Cortisol Adrenocorticotropic Reduces contractility of the smooth muscle Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Effects of Hormones Released (p. 191)
The uterus uses more glucose for energy Diverts blood from the uterus Increases tension of pelvic muscles; can impede fetal descent Increases perception of pain Ask students to develop a nursing diagnosis that addresses the maternal psyche during the labor process. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Abnormal Duration of Labor (p. 191)
Friedman’s curve Often used to graph the progress of cervical dilation and fetal descent Used as a guide to assess and manage the normal progress of labor Prolonged labor can cause Maternal or newborn infection Maternal exhaustion Postpartum hemorrhage Greater anxiety and fear When caring for a woman experiencing prolonged labor, it is vital that the nurse assist the woman to conserve her strength. Another key intervention involves providing encouragement to the laboring woman. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Precipitate Birth (p. 191) A birth that is completed in less than 3 hours Labor begins abruptly and intensifies quickly Contractions may be frequent and intense May have uterine rupture, cervical lacerations, or hematoma Fetal oxygenation may be compromised Birth injury may occur from rapid passage through the birth canal Injuries can include Intracranial hemorrhage Nerve damage Identify populations that could be at an increased risk for a precipitate birth. Review the role of the nurse when caring for the woman who experiences a precipitate delivery. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Premature Rupture of Membranes (PROM) (p. 192)
Spontaneous rupture of membranes at term, more than 1 hour before labor contractions begin Vaginal or cervical infection may cause PROM Diagnosis confirmed by Nitrazine paper test Looking for a “ferning” pattern from vaginal fluid placed on a and viewed under the microscope Prompt identification of membrane rupture is needed to plan and provide adequate care to the patient. Women who suspect their membranes have ruptured should be advised to report to their health care facility/provider for further evaluation. What are the increased risks for the pregnant woman who has experienced premature membrane rupture? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Patient Teaching for a Woman with Infection or in Preterm Labor (p
Report a temperature that is above 38° C (100.4° F) Avoid sexual intercourse or insertion of anything into vagina Avoid orgasms Avoid breast stimulation Maintain any activity restrictions prescribed Note any uterine contractions, reduced fetal activity, and other signs of infection Record fetal kick counts daily and report fewer than 10 kicks in a 12-hour period Premature labor is defined as the onset of labor between 20 and 37 weeks gestation. Discuss the nursing assessment for the patient who has preterm labor. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Preterm Labor (p. 192) Occurs after 20 weeks and before 37 weeks gestation Main risks are problems of immaturity in the newborn Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Some Risk Factors for Preterm Labor (p. 192)
Exposure to DES Underweight Chronic illness Dehydration Preeclampsia Previous preterm labor or birth Previous pregnancy losses Substance abuse Chronic stress Infection Anemia Preterm PROM Inadequate prenatal care Poor nutrition Low education level Poverty Smoking Multifetal presentation Review the underlying pathology of patients at an increased risk with these particular conditions. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Signs of Impending Preterm Labor (p. 193)
A shortened cervix on ultrasound at 20 weeks may be predictive of preterm labor A fibronectin test The presence of fibronectin in vaginal secretions between 22 and 24 weeks gestation is predictive of preterm labor Fibronectin is a protein produced by the fetal membranes that can leak into vaginal secretions if uterine activity, infection, or cervical effacement occurs Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Maternal Symptoms of Preterm Labor (p. 193)
Contractions that may be either uncomfortable or painless Feeling that the fetus is “balling up” frequently Menstrual-like cramps Constant low backache Pelvic pressure or a feeling that the fetus is pushing down A change in vaginal discharge Abdominal cramps with or without diarrhea Pain or discomfort in the vulva or thighs “Just feeling bad” or “coming down with something” Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Tocolytic Therapy (p. 193) Goal is to stop uterine contractions
Keep fetus in utero until lungs are mature enough to adapt to extrauterine life Magnesium sulfate IV drug of choice Beta-adrenergic drugs given orally Prostaglandin synthesis inhibitors Calcium channel blockers given orally Contraindications Preeclampsia Placenta previa Abruptio placentae Chorioamnionitis Fetal demise When tocolytic therapy is utilized to manage preterm labor, nursing assessments are a key part of the plan of care. Discuss the nursing assessments for the patient who is undergoing tocolytic therapy. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Stopping Preterm Labor (p. 193)
Initial measures to stop preterm labor Identifying and treating infection Activity restriction Hydration If it appears preterm birth is inevitable Steroids increase fetal lung maturity Betamethasone Thyroid-releasing hormone also enhances lung maturity in fetuses younger than 28 weeks Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Prolonged Pregnancy (p. 194)
Lasts longer than 42 weeks Risks Placenta ages Delivers oxygen and nutrients to the fetus less efficiently Fetus may lose weight Fetal skin may peel Fetus continues to grow Meconium may be expelled Low blood glucose levels in the fetus When a pregnancy continues longer than 42 weeks, it is considered postdate. Which patients are at greater risk for a prolonged pregnancy? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Tests Used to Confirm the Diagnosis of Prolonged Pregnancy (p. 194)
Any pregnancy that lasts longer than 40 weeks may require Nonstress tests (NST) Amniotic fluid index (AFI) Biophysical profiles (BPP) Kick counts Review the listed procedures. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Emergencies During Childbirth (p. 194)
Prolapsed umbilical cord Complete Palpated Occult Uterine rupture Incomplete Dehiscence The prolapsed cord can be classified as complete, palpated, or occult. Can you describe each of the types? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Prolapsed Umbilical Cord (p. 194)
Review the patient scenarios that are most likely to accompany a prolapsed umbilical cord. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Uterine Rupture (pp. 195-196) Types Risk Factors
Complete rupture—hole in uterine wall, into abdominal cavity Incomplete rupture—tears into a nearby structure; e.g., ligament but not all the way into the abdominal cavity Dehiscence—old uterine scar separate Risk Factors Low transverse incision is the least likely to rupture Uterine tachysystole increases risk if labor induced with oxytocin Blunt abdominal trauma Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Characteristics of Uterine Rupture (p. 195)
Shock caused by bleeding into the abdomen (vaginal bleeding may be minimal) Abdominal pain Pain in the chest, between the scapulae (shoulder blades), or with inspiration Cessation of contractions Abnormal or absent fetal heart tones Palpation of the fetus outside the uterus because the fetus has pushed through the torn area Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Amniotic Fluid Embolism (p. 196)
Occurs when amniotic fluid, with its particles such as vernix, fetal hair, and sometimes meconium, enters the woman’s circulation and typically obstructs small blood vessels in her lungs Characterized by abrupt onset of hypotension, respiratory distress, and coagulation abnormalities from thromboplastin in amniotic fluid Another serious complication of childbirth is an amniotic fluid embolism. Prompt identification of the phenomenon is required to save the woman’s life. Develop a nursing diagnosis for the woman who has experienced an amniotic fluid embolus. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Treatment for Amniotic Fluid Embolism (p. 196)
Mechanical ventilation Treat shock with electrolytes and volume expanders Replace coagulation factors; e.g., platelets and fibrinogen PRBC sometimes provided I&O monitored closely Pulse oximetry Cardiac monitoring Transfer to ICU Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

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