1. High Risk Labor and Births Chapter 21
Mary L. Dunlap MSN
Fall 2015

2. Labor and Birth at Risk Dysfunctional Labor
Dystocia- abnormal or difficult labor
Leading indicator for primary cesarean sections in the USA
Early identification and prompt interventions help to minimize risk to mother and fetus

3. Dystocia Factors Maternal positioning Powers Passenger Passageway
Maternal stress (psyche)
Table 21.1 pg

4. Maternal positioning Can interfere with the decent of the fetus
Maternal built
Uterine abnormalities/congenital malformations

5. Uterine Contractions Hypertonic
Uterus never fully relaxes between contractions
Strong, painful, ineffective contractions
Contributing factor- maternal anxiety
Management
Rest, hydration, sedation

6. Uterine Contractions Hypotonic Decrease in frequency and intensity
Management
Ambulation
Position change
Augmentation

7. Uterine Contractions Precipitous Labor and Birth
Rapid intense contractions
Fetus delivered rapidly (less than 3 hrs.)
Management
Monitor progression of labor
Reassure and support patient
Breathing to avoid pushing and prevent tearing

8. Passenger Persistent occiput posterior position Breech presentation
Shoulder dystocia
Multiple gestation
Macrosomia

9. Passageway
Contraction of one or more of the three planes of the maternal pelvis: inlet, midpelvis, and outlet
Obstruction in the birth canal: placenta Previa, uterine fibroids, full bladder and cervical swelling

10. Maternal Psyche Emotions
Fear, Anxiety, Helplessness, Exhaustion and Feeling alone cause psychological stress
Management
Provide physical and emotional support
Comfort measures
Pain management

11. Preterm Labor and Birth
Preterm labor: cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy
Preterm birth: any birth that occurs before the completion of 37 weeks of pregnancy

12. Preterm Labor and Birth
Risk Factors
Infections
Low Socioeconomic status
Smoking
Little or no prenatal care
Domestic violence
Box pg.722

13. Preterm Labor and Birth
Predicting preterm labor and birth
Fetal Fibronectin
Salivary Estriol
Transvaginal U.S.
Home Monitoring

14. Preterm Labor and Birth
Uterine contractions
Pattern more frequent than every 10 minutes persisting for 1 hour or more
Discomfort
Dull, intermittent low back pain
Menstrual like cramps

15. Preterm Labor and Birth
Suprapubic pain or pressure
Pelvic pressure or heaviness
Urinary frequency
Vaginal discharge
Change in discharge
Rupture of amniotic membranes

16. Preterm Labor and Birth
Prevention
Educate woman about early symptoms of preterm labor
Any symptoms of uterine contractions or cramping between 20 and 37 weeks of gestation that do not go away are not normal discomforts of pregnancy require contacting primary health care provider

17. Preterm Labor and Birth
Lifestyle modifications
Activities resulting in preterm labor
Sexual activity
Carrying heavy loads
Standing more than 50% of the time
Heavy housework or climbing stairs
Hard physical work
Being unable to stop and rest when tired
Teaching Guidelines 21.1 pg. 724

18. Preterm Labor Management
Bed rest
Commonly used for prevention of preterm birth
No evidence to support effectiveness in reducing preterm birth rates
Tocolytics- suppression of uterine activity
Glucocorticoid to help accelerate fetal lung maturity

19. Preterm Labor and Birth
Management of inevitable preterm birth
4cm dilation inevitable preterm birth
Births in tertiary centers better neonatal and maternal outcomes
Women at risk improved outcome at tertiary center
Administer Glucocorticoids before transfer

20. Prolonged Pregnancy Continues beyond 42 weeks gestation
Risk for fetal/neonatal problems
Increase risk for cesarean birth due to utero-placental insufficiencies

21. Post Term Labor and Birth
Maternal risks related to Fetal Macrosomia
Dystocia of labor
Infection
Birth trauma
Post partum hemorrhage

22. Post Term Labor and Birth
Fetal Risks
Asphyxia
Meconium aspiration
Hypoglycemia
Respiratory distress
Macrosomia- Brachial plexus injuries
12310

23. Post Term Labor and Birth
Management
Induction of labor
Monitor fetus for signs of uteroplacental insufficiencies

24. Induction/Augmentation of Labor
The stimulation of uterine contractions by medical and surgical means to produce delivery before the onset of spontaneous labor.
Augmentation enhances ineffective contractions after labor has begun

25. Induction/Augmentation of Labor
Considerations for induction
Post term
Prolonged rupture of membranes
Gestational hypertension
Preeclampsia
Diabetes
Fetal demise
ACOG 1999 indicators for induction

26. Induction/Augmentation of Labor
Risks
Cesarean delivery
Instrumented assisted delivery
Epidural analgesia
Fetal stress and admission to neonatal intensive care unit

27. Induction Contraindications
Complete Previa
Abruptio placenta
Transverse lie
Prolapsed umbilical cord
Previous Myomectomy
Herpes
Previous C/Sec

28. Induction/Augmentation of Labor
Bishop
Score 1 2 3
Dilatation
1-2
3-4
5 or more
Effacement
0-30%
40-50%
60-70%
80-100%
Station -3 -2 -1
+1 +2
Cervical consistency
Firm
Med
Soft
Cervix
position
Posterior
Mid
Anterior

29. Cervical Ripening Methods
Nonpharmacologic
Mechanical
Surgical
Pharmacologic

30. Nonpharmacologic Methods
Herbal agents
Castor oil
Enemas
Sexual intercourse
Breast stimulation

31. Mechanical Method
Application of Local pressure to the cervix stimulating the release of prostaglandins to ripen the cervix
Foley catheter inserted into Endocervical canal to ripen & dilate cervix
Hygroscopic dilators absorb Endocervical & local tissue fluids; as they enlarge they create mechanical pressure (Laminaria)

32. Surgical Methods
Stripping of membranes- place a finger through the cervix and move it in a circular direction causing the membranes to detach
Amniotomy with an Amniohook fetal head now applies pressure to the cervix stimulating increase in prostaglandins

33. Pharmacological
Prostaglandins
Oxytocin
Drug Guide pg.729

34. Oxytocin (Pitocin) Hormone produced by posterior pituitary gland
Stimulates uterine contractions
Used to induce labor or to augment a labor progressing slowly because of inadequate uterine contractions

35. Oxytocin (Pitocin)
Oxytocin is always administered by infusion pump piggybacked into the main line at the closest port to the insertion site
Start induction at 1-2 mU/min
Increase rate q min by 1-2mU until a contraction pattern of q 2-3 min lasting for 40 to 60 sec.

36. Oxytocin (Pitocin)
Continuous fetal monitor to evaluate contraction pattern and FHR
Prior to starting induction verify term pregnancy and vertex position
If Hyperstimulation occurs turn Oxytocin infusion off to let the uterus rest and notify Provider

38. Premature Rupture of Membranes
Rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of labor at any gestational age

39. Preterm Premature Rupture of Membranes (PPROM)
Rupture before 37 weeks gestation
Occurs in up to 25% of preterm labors
Often preceded by infection
Etiology unknown
Diagnosed after woman complains of sudden gush or slow leak of vaginal fluid

40. Birth Related Interventions
Amnioinfusion
Forceps/Vacuum assisted delivery
Episiotomy
Cesarean section
VBAC

41. Amnioinfusion
Warm sterile NS or RL IV solution is infused into the uterus through an intrauterine pressure catheter to increase the amniotic fluid volume
Cushion the umbilical cord
To help thin meconium

42. Amnioinfusion
Contraindications: vaginal bleeding of unknown origin, umbilical cord prolapse, amnionitis, uterine hypertonicity and sever fetal distress
Follow hospital policy for infusion
Complications: abruption, cord prolapse, fetal hypothermia

43. Forceps-Vacuum Assisted Birth
Prolonged second stage
Fetal distress
Abnormal presentations
Arrest of rotation
Delivery of head in a breech presentation

44. Forceps

45. Birth Related Interventions
Vacuum-assisted
Vacuum applied to fetal head, negative pressure to assist birth of head
Prerequisites
Vertex presentation
Ruptured membranes
Absence of CPD

48. Episiotomy Incision made in the perineum to enlarge the vaginal outlet
Locations- midline, R or L Mediolateral
Alternative measures- warm compresses, massage with oil have been successful in stretching perineal area

49. Cesarean Birth
The delivery of the fetus through an incision in the abdomen and uterus
Classical
Low Transverse
USA 1 in 3 births

50. Cesarean Birth indications
Recognition of fetal distress due to Electronic fetal monitoring
Preserve life of mother and fetus
Failed labor
Failed VBAC

51. Cesarean Birth Complications and Risks Anesthesia
Surgical complications
Impaired bonding
Post partum complications

52. Cesarean Birth Preoperative care Intraoperative care
Immediate postoperative care
Postpartum care

53. Cesarean Birth
Cesarean Birth

54. Vaginal delivery after a Cesarean (VBAC)
A woman who has had a previous cesarean and gives birth vaginally after at least one previous cesarean birth.
Controversial choice
Risk for uterine rupture, hemorrhage and fetal mortality

55. VBAC Contraindications Prior classic uterine incision
Uterine scar other than a low transverse
Prior transfundal uterine surgery
Inadequate staff or facility
Use of cervical ripening agents

56. VBAC
Special areas of focus: consent, documentation, surveillance, and readiness for emergency
Nursing care is focused FHR tracing to identify nonreassuring pattern and instituting measures for emergency delivery

57. Obstetric Emergencies
Umbilical cord prolapse
Placenta Previa
Placental abruption
Uterine rupture
Shoulder Dystocia
Fetal Demise

58. Cord Prolapse Lies below presenting part of fetus Contributing factors
Long cord (longer than 100 cm)
Malpresentation (breech)
Transverse lie
Unengaged presenting part
Hydramnios

59. Cord Prolapse

60. Cord Prolapse Management
Hold the presenting part off the umbilical cord until delivery
Change patients position to relieve cord pressure
Monitor fetal heart rate
Emotional support
Pre-per for c/sec

61. Cord Prolapse

62. Cord Prolapse

63. Placenta Previa Placental implantation in the lower uterine segment
Position can create a barrier for vaginal delivery of the fetus

64. Placental Abruption Premature separation of placenta Management
Based on gestational age, extent of hemorrhage and maternal-fetal oxygenation perfusion
Maintain maternal cardiovascular status
Prompt delivery
Cesarean birth if fetus still alive; vaginal birth if fetal demise

65. Uterine Rupture Uterine tearing at the site of a previous scar. Causes
Uterine trauma: accidents, surgery
Congenital uterine anomaly
Intense uterine contractions

66. Uterine Rupture Causes Labor stimulation Over distended uterus
Malpresentation: external or internal version
Difficult forceps-assisted birth
More often in Multigravidas

67. Uterine Rupture Management Pre pare mother for Stat emergency C/sec
Administer IV fluid & blood to combat hemorrhage
O2 to help with fetal compromised
Mother will be anxious stay calm

68. Shoulder Dystocia
Head is born, anterior shoulder cannot pass under pubic arch
Delivery can cause newborn birth injuries
Maternal risk: excessive blood loss, lacerations, extension of episiotomy, or Endometritis

69. Shoulder Dystocia
Management
McRoberts maneuver
Suprapubic pressure

71. McRoberts

72. Suprapubic pressure

73. Shoulder Dystocia Shoulder Dystocia simulation
Shoulder Dystocia delivery