1. Nursing Care of Women with Complications During Labor and Birth
Chapter 8
Nursing Care of Women with Complications During Labor and Birth

2. Obstetric Procedures (p. 174)
Amnioinfusion
Oligohydramnios
Umbilical cord compression
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.

3. 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

4. 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?

5. 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.

6. 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.

7. 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.

8. 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

9. 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?

10. Dilating the Cervix (p. 176)
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.

11. 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
Prior to an amniotomy, a series of assessments must be completed.
What are the needed assessments?

12. 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.

13. 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

14. Pharmacological Methods to Stimulate Contractions (p. 177)
Oxytocin Induction-initiates or stimulation of contractions with oxytocin (Pitocin) most common
Diluted in IV fluids-started as IVPB
Regulated with infusion pump
Begins a low rate

15. Nonpharmacological Methods to Stimulate Contractions (p. 177)
Walking or Sitting Upright
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
Brush with dry washcloth; gently pulling on nipples; applying suction with breast pump

16. Complications of Augmentation of Labor (p. 177)
Most common is related to
Overstimulation of contractions
Fetal compromise
Due to blood flow to the placenta if contractions are tachysystole
Uterine rupture
Water intoxication
Inhibits excretion of urine and promotes fluid retention
View the nursing assessments that must accompany oxytocin administration.

17. 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.

18. 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.

19. 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.

20. 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?

21. 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

22. 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

23. 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.

24. 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
May apply ice pack for at least 12 hours after hours may apply heat
Infant may have bruising, facial or scalp lacerations or abrasions, cephalohematoma, or intracranial hemorrhage with the use of forceps-nurse must assess
If vacuum extraction-may have a “chignon” will disappear soon after birth

25. 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?

26. 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

27. 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?

28. 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

29. 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?

30. 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

31. 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?

32. 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?

33. 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
When assessing the uterine fundus support lower portion of uterus and with the fingers of the other hand “walk” from the side toward the midline to upper fundus of uterus

34. 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?

35. 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.

36. 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.

37. 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
If no progression in labor in patient will be having an amniotomy, to help stimulate uterus to contract

38. Ineffective Maternal Pushing (p. 187)
Woman may not understand which technique to use or fears tearing her perineal tissues
Woman will need to be assisted with frequent changes in position
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?

39. 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.

40. 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.

41. 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

42. Abnormal Fetal Presentation or Position (p. 189)
Prevents the smallest diameter of the fetal head to pass through the smallest diameter of the pelvis
The most effective, efficient fetal position is flexed and cephalic.
What fetal head presentation is best? Occiput anterior

43. Abnormal Presentations (p. 189)
Does not pass easily
Interferes with most efficient mechanisms of labor
Can cause cord compression
May require external version

44. 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

45. 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

46. 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?

47. Problems with the Pelvis and Soft Tissues (pp. 190-191)
Bony pelvis
Gynecoid pelvis most favorable for vaginal birth
Soft tissue obstructions
Most common is a full bladder
Scarring from previous uterine surgery may not yield to labor’s forces to efface and dilate.

48. 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

49. Increased Anxiety (p. 191) Causes hormones to be released
Epinephrine
Cortisol
Adrenocorticotropic
Reduces contractility of the smooth muscle and blood supply to the uterus
When patient presents with dilated cervix close to or at 10 you will need to help her gain control by helping her with breathing in order to help gain control of contractions

50. 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.

51. 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.

52. Precipitate Birth (p. 191)
A birth that is completed in less than 3 hours and should be assessed first when on floor
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.

53. 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?

54. 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.

55. Preterm Labor (p. 192)
Occurs after 20 weeks and before 37 weeks gestation
Main risks are problems of immaturity in the newborn
Complication to assess for is chorioamnionitis or inflammation of the fetal membranes

56. 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.

57. 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

58. 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”

59. 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
IV line is started-inform patient that she will feel a warm flush when the drug is started
Beta-adrenergic drugs given orally
Beta-adrenergic drugs given subcutaneously ass for possible tachycardia and blood pressure
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.

60. 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

61. 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?

62. 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.

63. Emergencies During Childbirth (p. 194)
Prolapsed umbilical cord
Complete
Palpated
Occult
Nursing Care will include repositioning the mother in knee-chest or Trendelenburg position in order to displace the fetus
Uterine rupture
Incomplete
Dehiscence
The prolapsed cord can be classified as complete, palpated, or occult.
Can you describe each of the types?

64. 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

65. 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

66. 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.

67. 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