1. CHILDBIRTH AT RISK
Chapter 21

2. 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

3. 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

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

5. 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

6. 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

7. 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

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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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?)

19. 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

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

21. 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

22. 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

23. 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

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Fetal Death

32. 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

33. 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

34. 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

35. 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

36. 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.

37. 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

38. 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

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

40. 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

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

42. 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.

43. 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.

44. 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