Nursing Management of Labor and Birth at Risk

By: Faith Angeline C. Fernandez

Dysfunctional labor Problems with Power, Passenger, Passage and Psyche Post-term with Labor and Birth Women requiring Induction & Augmentation Intrauterine Fetal Demise Obstetric Emergencies Birth Related Procedures

Difficult labor -Dystocia

Definition
Difficult labor or childbirth Abnormal slow progress of labor

Incidence
The most common indication for primary cesarean section

Evaluation index
Cervical dilation Descent of the fetal presentation

Classification of Dystocia
Abnormalities of the Power Abnormalities of the Passage Abnormalities of the Passenger Abnormalities of the Psyche

Characteristics of the

power

Intensity is greater in the fundus Average 24mmHg Well synchronized Frequency Duration 60s regular Rhythm and force Basal resting pressure 12-15mmHg

Abnormalities in Power
Inertia is a time honored term to denote that sluggishness of a contractions, or the force of labor, has occurred. More current term is dysfunctional labor Occurring at the onset in labor Occurring later in labor

Abnormalities in Power
Prolonged labor appears to result from several factors. It is more likely to occur if the fetus is large Hypotonic, hypertonic and uncoordinated contractions

Fetal monitoring

Uterine dysfunction
Hypotonic Hypertonic Uncoordinated Inadequate expulsive efforts

Hypotonic dysfunction
Management:

Insufficien t Irregular Infrequent

Infusion of oxytocin Membranes may be artificially ruptured (amniotomy)

Hypotonic dysfunction
Post Partal Period Management:

In the 1st hour after birth

o Palpate the uterus o Assess lochia every 15 minutes

Hypotonic dysfunction

etiology
Malfunction Malpresentation Extrinsic factor

Hypertonic dysfunction
Management :

Lack of resting tone Frequent intense contraction

Morphine Sulfate/Sedation I and E monitoring Darkening the room lights Decreasing noise Cesarean section

Hypertonic Dysfunction

Hypertonic dysfunction etiology

Muscle fibers of the myometrium do not repolarize.

Uncoordinated Contrations
Dyssynchronu s Frequent Management: I and E monitoring Oxytocin

Comparison of Hypotonic and Hypertonic Contractions

Criteria Hypertonic Hypotonic Phase of Latent Active labor Symptoms Painful Painless Medication Oxytocin Unfavorabl Favorable e reaction Reaction Sedation Helpful Little value

Abnormal patterns
Prolonged latent phase Protraction disorders (active phase) Arrest disorders (active phase) Precipitate labor disorders

Friedmans curve

Active phase II stage

Latent phase

Partogram

Prolonged latent phase

Normal average Prolonged

Nulliparas

6.4 hr 4.8 hr

>20 hr > 14 hr

Multipara s

Prolonged latent phase

Management: Administration of morphine may relax hypertonicity Administering adequate fluid Amniotomy Oxytocin infusion Cesarean Birth

Protraction Active Phase

Dilation Nulliparas Multiparas Descent Average 8hr 5hr <1.2 cm/h <1.0 cm/h <1.5 cm/h <2.0 cm/h

Protraction Active Phase

Management: Oxytocin Cesarean Birth

Arrest disorder
Dilation Nulliparas Multiparas >2h >1h Descent >2h >1h

Arrest disorder
Management: Cesarean Birth Oxytocin

Partogram

Abnormal partogram

A prolonged latent phase B prolonged active phase C arrest active phase

Partogram

Pathological retraction ring

Occurs at the junction of the upper and lower uterine segments 2nd stage of labor: o Severe dysfunction labor is occurring. Formed by excessive retraction of the upper uterine segment; the myometrium is much thicker above than below the ring Early stage of labor: o Caused by uncoordinated contractions.

Pathological retraction ring

Management: Administration of morphine sulfate Inhalation of amyl nitrite Tocolytic

Pathological retraction ring

retraction ring (bandls ring)

Precipitate labor disorders

Dilation Nulliparas Multiparas >5cm/hr >10cm/hr Descent >5cm/hr >10cm/hr

Precipitate labor disorders

Management: Tocolytic - to reduce the force and frequency of the contraction

Abnormalities of the
Passage
Bony pelvic (most common) Soft tissue obstruction Abnormal placenta location

Bony pelvic abnormalities

Inlet Contraction Generally contracted pelvis Deformed pelvis

Three level of bony pelvis

Inlet contraction
Contraction of pelvic inlet AP<11cm; transverse<12 cm Contraction of mid-pelvis interischial spinous diameter <10cm Contraction of pelvic outlet interischial tuberous diameter <11cm

Three anteroposterior diameters of the pelvic inlet

Examination

Diameter of the inlet and midpelvis

Fetopelvic disproportion

36.6%

10.9%

transversely contracted Pelvis

Flat(platypelloid) 47.3%

anthropoid
5.8%

funnel shaped pelvis

gynecoid

android

each pelvic plane is 2 cm less than normal

generally contracted pelvis

Deformed pelvis
osteomalacia oblique pelvis

kyphosis

Soft tissue dystocia

Congenital anomalies Scarring of birth canal Pelvic masses

Pelvic mass

Pelvic mass

Low lying placenta

Abnormalities of the
Passenger
Prolapse of the Umbilical Cord Fetal macrosomia Malpresentation Shoulder dystocia Fetal malformation

11.3

9.5
13.3

Prolapse of the umbilical cord

A loop cord slips down in front of the presenting part. Prolapse may occur at any time after the membranes rupture if the presenting part is not fitted firmly into the cervix.

Prolapse of the umbilical cord

It tends to occur most often with the ff. conditions:
o Premature rupture of the membrane o Placenta previa o A small fetus o Hydramnious o Multiple gestation o CPD preventing firm engagement

Prolapse of the umbilical cord

Management: Administering Oxygen at 10 L/min by facemask is also helpful to improve the oxygenation of the fetus Aimed toward relieving pressure on the cord Placing a gloved hand in the vagina and manually elevating the fetal head of the cord Knee chest position or trendelenburg position which causes the fetal head fall back from the cord

 Do not attempt to push back any exposed cord. This may add to the compression by causing knotting or kinking. Cover any exposed portion with sterile saline compress to prevent drying Deliver the infant quickly, possibly with Forcep delivery to prevent fetal anoxia

Prolapse of the umbilical cord

Fetal Macrosomia
Size may become a problem in a fetus who weighs more than 4,000 4,500g (9-10lbs.) An oversized infant may cause uterine dysfunction during labor or at birth because of over stretching of the fibers of the myometrium. A large infant born vaginally has a higher than normal risk of: o Cervical nerve palsy o Diaphragmatic nerve injury o Fractured clavicle because of shoulder dystocia o Hemorrhage

Fetal macrosomia
large for gestational age(LGA) 4000g

Fetal macrosomia
Management:
Pelvimetry or Sonography can be used to compare the size of the fetus with the womans pelvic capacity Cesarean section

Malpresentation
In approximately 1/10th of all labors, the fetal position is posterior rather than anterior. Posterior position tend to occur in women with android, anthropoid or contracted pelvis. A posterior position is suggested by a dysfunctional labor pattern such as a prolonged active phase, arrested descent or fetal heart sounds best heard at the lateral sides of the abdomen.

Malpresentation
Breech presentation Face presentation Brow presentation Transverse Lie

Cepholic position and the diameter through pelvis

parietal occiput presentation presentation brow presentation face presentation

Malpresentation

Breech presentation

Shoulder dystocia
Is a birth problem that is increasing in incidence along with the increasing average of new born. The problem occurs at the second stage of labor, when the fetal head is born but the shoulders are too broad to enter and born through the pelvic inlet. The force of birth can result in a fractured clavicle or a brachial plexus in jury for the fetus.

Shoulder dystocia

Shoulder presentation

Brachial Plexus Injury

Fetal malformation

Psyche
The fourth P refers to the psychological feelings that a woman brings into labor. For many women, apprehension or fright. this feeling of

Women who manage best in labor typically are those who have a strong sense of self-esteem and a meaningful support person with them.

Psyche
Women without adequate support can have an experience so frightening and stressful they can develop a post traumatic stress syndrome.

Psyche
Management: Encouraging women to ask questions at prenatal visits and to attend preparation for childbirth classes helps prepare them for labor. Encouraging them to share their experience after labor serves as debriefing time and helps them integrate the experience into their total life

Induction and Augmentation of Labor

Induction and Augmentation of Labor

Induction of Labor means that labor is started artificially Augmentation refers to assisting labor that has started spontaneously to be more effective. Induction may be necessary to initiate labor before the time when it would have occurred spontaneously because the fetus is in danger or labor does not occur spontaneously and the fetus appears to be at term.

Indication for induction of labor

Primary reason for induction of labor include the presence of: o Preeclampsia/Eclampsia o Diabetes mellitus o Prolonged rupture of the membranes o Postterm pregnancy o Rh incompatibility o Intrauterine fetal demise (iufd) o Intrauterine growth retardation

Indication for augmentation

Or assistance to make uterine contractions stronger may be necessary if the contractions are hypotonic or too weak or infrequent to be effective. Prolonged labor Dysfunctional labor Poor progress of cervical dilatation

o Fetus is estimated to be mature by date demonstrated by a lecithin sphingomyelin or sonogram to rule out preterm

Induction and Augmentation of Labor

Before induction of labor is begun, the ff. conditions should be present: o Fetus is in longitudinal lie o Cervix is ripe, or ready for birth o Presenting part is engaged o No CPD

Learning Outcome
Compare the methods for inducing labor, explaining their advantages and disadvantages in determining the nursing management for women during labor induction.

Cervical Ripening
Consists of effacement and softening of the cervix May be used at or near term to enhance success of and reduce time needed for labor induction when continuing pregnancy is undesirable May hasten beginning of labor or shorten course of labor

Cervical Ripening
May cause hyperstimulation of uterus Pharmacologic agents include Cytotec and prostaglandin agents can cause uterine stimulation after insertion

Bishop criteria for scoring

Scoring factor Dilatation (cm) Effacement( %) Station Consistency Position 0 0 0-30 -3 Firm Posterior 1 1-2 40-50 -2 Medium Midposition 2 3-4 60-70 -1-0 Soft Anterior 3 3-4 80 +1-+2

Stripping of the Membranes

Mechanical method: Gloved finger inserted into internal os and rotated 360 degrees twice separating amniotic membranes lying against lower uterine segment

Stripping of the Membranes

Disadvantages: Does not require monitoring or other assessments often done as outpatient service May not induce labor if labor is initiated, it typically begins within 48 hours May cause bleeding

Oxytocin induction
Administration of oxytocin initiates contraction in a uterus at pregnancy term. Oxytocin is always administered intravenously, so, hyperstimulation should occur. It can be quickly discontinued.

Pitocin Infusion
Usually effective at producing contractions may cause hyperstimulation of the uterus Requires small, precise dosage 10 IU in 1,000 mL of Ringers Lactate. An alternative dilution method is to add 15 IU of oxytocin to 250 mL of an IV solutio; this yields of concentration of 60 mU/1mL.

Pitocin Infusion
Maximum rate and dosing interval based on facility protocol, clinician order, individual situation, and maternal-fetal response Infusion are usually begun at a rate of 0.5 to 1 mU/min until contraction begin. Do not increase the rate to more than 20 mU/min without checking further instructions, due to an administration rate greater than this is likely to cause tetanic contractions.

Pitocin Infusion
Management: Take the womans pulse and BP every 15 minutes Monitor uterine contractions conscientiously Contractions should occur no more often than every 2 minutes, should not be stronger than 50 mmHg preassure and should not lst longer than 70 seconds.

Pitocin Infusion
B-adrenergic receptor drug such as terbutaline sulfate (Brethine)or Magnesium Sulfate may prescribed to decrease myometrial activity. Anti diuretic effect:
o o o o o Decreased urine flow Headache and vomiting Keep accurate record of I and O Test and record urine specific gravity Limit the amount of fluid (150mL/hr) by ensuring that the main IV fluid line is infusing at a rate not greater than 2.5 mL/min.

Augmentation by oxytocin
Is required if labor contractions begins spontaneously but then become so weak, irregular, or ineffective (hypotonic) that assistance is needed to strengthen them. Precautions regarding oxytocin augmentation are the same as for primary induction of labor. Be certain that the drug is increased in small increments only and that fetal heart sounds are well monitored during procedure.

Active management of Labor

It include the aggressive administration of oxytocin to shorten labor to 12 hours, which presumably reduces the incidence of CS birth and post partal infection. The Maximum dosage may be as high as 36 40 mU/min.

Birth-Related Procedures

External Version
May be done 37 to 38 weeks gestation to change breech presentation to cephalic presentation before birth Physician applies external manipulation to maternal abdomen. gentle pressure is then exerted to rotate the fetus in a forward direction to cephalic lie Fetal part must not be engaged.

External Version
Management before the procedure: NST performed to establish fetal wellbeing Tocolytic given during procedure to relax the uterus

Transverse fetal lie

Internal Version
Podalic version used to turn second twin during vaginal birth Used only if second fetus does not descend readily and heartbeat is not assuring Physician reaches into uterus and grabs feet of fetus and pulls them down through cervix

Internal Version
Management before the procedure: Tocolytic given during procedure to relax the uterus

Purpose of Amniotomy
Stimulate or induce labor Apply internal fetal or contraction monitors Obtain fetal scalp blood sample for pH monitoring Assess color and composition of amniotic fluid

Episiotomy Types
Surgical incision of perineal body to enlarge outlet commonly used to avoid spontaneous laceration

Episiotomy Types
Two types o Midline: Incision begins at bottom center of perineal body and extends straight down midline to fibers o Mediolateral: Incision begins in midline of posterior fourchette and extends at 45 degree angle downward to right or left

Episiotomy Types
Episiotomy usually performed with regional or local anesthesia

Types of Episiotomy

Nursing Care
During procedure, provide mother with support and comfort Use distraction if needed if procedure is uncomfortable, act as advocate for mother Document type of episiotomy in records and report to subsequent caregivers After procedure, provide comfort and apply ice pack

Nursing Care
Assess perineal area frequently inspect every 15 minutes during first hour after birth for redness, edema, tenderness, ecchymosis, and hematomas Apply ice pack immediately in fourth stage Instruct mother in perineal hygiene and comfort measures

Inadequate expulsive efforts

Second stage Assisted delivery might be needed Analgesic / anesthetic agents wear off

Operative delivery
1)forceps operations

Indications
Maternal heart disease Maternal pulmonary edema Maternal infection Maternal exhaustion Fetal stress

Indications
Premature placental separation Need for shorter second stage of labor Heavy regional block with ineffective pushing

Applications of Forceps

Applications of Forceps

Applications of Forceps

Risks
Newborn may experience
o Bruising o Edema o Facial lacerations o Cephalhematoma o Transient facial paralysis o Cerebral hemorrhage

Risks
Woman may experience
o Vaginal or perineal lacerations o Infection secondary to lacerations o Increased bleeding o Bruising o Perineal edema

Learning Outcome
Describe the use of and risk of vacuum extraction use to assist birth.

Operative delivery Vacuum

Vacuum Extractor
Assists birth by applying suction to fetal head Should be progressive descent with first two pulls, procedure should be limited to prevent cephalhematoma risk increases if birth not within six minutes Increases risk for jaundice due to reabsorption of bruising at cup attachment site

Vacuum Extractor

Learning Outcome
Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing care.

Indications
Most common indications for cesarean birth
o Fetal distress o Active genital herpes o Multiple gestation (three or more fetuses) o Umbilical cord prolapse o Tumors that obstruct birth canal o Lack of labor progression

Indications
Most common indications for cesarean birth
o o o o o o Maternal infection Pelvic size disproportion Placenta previa Abruptio Placenta Previous cesarean section Eclampsia

Teaching
Teaching needs include o What to expect before, during, and after delivery o Why it is being done o What sensations the woman will experience o Role of significant others o Interaction with newborn

Cesarean Section
Performed when mom or fetus in danger If in moms history, ask why section done. May give you clues as to past delivery complications

Preparation
Preparation for cesarean birth requires
o Establishing IV lines o Placing indwelling catheter o Performing abdominal prep

Cesarean Section

Uterine Incisions for Cesarean Birth

Uterine Incisions for Cesarean Birth

Uterine Incisions for Cesarean Birth

Nursing Care
Routine postpartal care including:
o Fundal checks o Care of incision o Monitoring Intake & Output and maintaining IV access o Administer and teach about post-op medications o Assessment of respiratory system o Assessment of bowel sounds

Learning Outcome
Examine the risks, guidelines, and nursing care of the woman undergoing vaginal birth following cesarean birth.

Vaginal Birth After Cesarean Birth

Can occur after trial of labor in cases of nonrecurring indications for cesarean birth Most common risks are
o Hemorrhage o Surgical injuries o Uterine rupture o Infant death or neurological complications

When crowning, apply gentle pressure to infants head

Vaginal Delivery

Vaginal Delivery
Examine neck for looped umbilical cord

Vaginal Delivery
Support infants head as it rotates for shoulder presentation

Nursing Care
Continuous EFM Internal Monitoring IV fluids Avoid Pitocin if at all possible Classic or T uterine incision is contraindication to VBAC

Nursing Care
Important for nurse to support couple, explore their feelings, and provide information throughout labor

Obstetric Emergencies

Nuchal Cord
Occurs in roughly 25% of all deliveries Cord wrapped around neck Can lead to decreased blood flow of infant

Preeclampsia
Unknown cause Often healthy, normotensive primigravida After twentieth week, often near term

Diagnosis of preeclampsia Hypertension

Proteinuria Excessive weight gain with edema

Blood pressure >140/90 mm Hg Acute rise of 20 mm Hg in systolic pressure or 10 mm Hg rise in diastolic pressure over prepregnancy levels

Management Treat hypertension, prevent seizures

Eclampsia
Same signs and symptoms plus seizures or coma Tonic-clonic activity Often begins as oral twitching Often apnea during seizure Can initiate labor

Management
Left lateral recumbent position Minimize stimulation Oxygen and ventilation assistance If seizures:
Monitor vital signs Safety of the patient

Gestational Diabetes Mellitus

Mother cant metabolize carbohydrates Excess glucose goes to fetus Stored as fat Management Glucose monitoring Diet Exercise Insulin

Vaginal Bleeding
Abortion (miscarriage) Ectopic pregnancy Abruptio placenta Placenta previa Uterine rupture Postpartum hemorrhage

Abortion
Termination of pregnancy from any cause before 20th week of gestation
Later is known as preterm birth

Common classifications of abortion Determine:

Onset of pain and bleeding Amount of blood loss If any tissue passed with blood

Management

Third-Trimester Bleeding 3% of pregnancies Never normal Most often due to: Abruptio placentae Placenta previa Uterine rupture

Abruptio Placenta
Partial or complete detachment of normally implanted placenta at more than 20 weeks gestation Predisposing factors Trauma Maternal hypertension Preeclampsia Multiparity Previous abruption

Placenta Previa
Sudden vaginal bleeding in 3rd trimester Pain Abdomen may be tender or rigid May be minimal bleeding with shock Most of hemorrhage may be hidden Contractions may be present If fetal heart tones absent, fetal death is likely

Placenta Previa
Placental implantation in lower uterine segment, encroaching on or covering cervical os 1 in 300 deliveries More common in preterm birth Painless, bright red bleeding Increases if labor begins Fetal compromise

Placenta Previa
More common with: Increased maternal age Multiparity Previous cesarean section Previous placenta previa

Uterine Rupture
Spontaneous or traumatic rupture of uterine wall Causes Previous scar opens Trauma Prolonged or obstructed labor Rare but accounts for 5%-15% maternal deaths 50% of fetal deaths

Uterine Rupture
Sudden abdominal pain Tearing Active labor Early signs of shock Vaginal bleeding May be hidden

Management of 3rd Trimester Bleeding

Prevent shock Do not examine patient vaginally May increase bleeding and start labor Emergency care ABCs Left lateral recumbent position Check fundal height

Post-term Pregnancy
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Definition
A pregnancy that persists for 42 weeks or more from the onset of the last menstrual period. Sometimes called postmaturity or postdate. Incidence: 5-10%. It is more common in primigravidae.

Etiology
Unknown, but hereditary, hormonal and non-engagement of the presenting part are suspected factors.

Risk of Post-term
A. Placental insufficiency: which may lead to fetal hypoxia or even death. B. Oligohydramnios: with its sequel particularly cord compression during labor. C. Obstructed labor: due to; * oversized baby, * no molding of the skull due to more calcification. D. Increased incidence of operative delivery.

Diagnosis
Antenatal > History: calculation of gestational age. > Examination: larger baby size. > X-ray: large ossification center in the upper end of the tibia. > Ultrasonography: can detect, Biparietal diameter more than 9.6 cm. Increased foetal weight. Oligohydramnios. Increased placental calcification. >Tests for placental function.

Diagnosis
Postnatal a. Baby length: more than 54 cm. b. Baby weight: more than 4.5 kg. c. Skull: well ossified with smaller fontanels. d. Finger nails: project beyond finger tips.

Management
Induction of labor if the condition is favorable for vaginal delivery using: > amniotomy oxytocin, or > prostaglandins oxytocin. Caesarean section: if conditions are not favorable for vaginal delivery, or if induction of labor failed.

Intrauterine Fetal Demise

Intrauterine Fetal Demise

A stillbirth occurs when a fetus has died in the uterus. The Australian definition specifies that fetal death is termed a stillbirth after 20 weeks gestation or the fetus weighs more than 400 grams (14oz). Once the fetus has died the mother still has contractions and remains undelivered. The term is often used in distinction to live birth or miscarriage. Most stillbirths occur in full term pregnancies.

Intrauterine Fetal Demise

Risk factors:
Alcohol abuse, drug use and smoking due to inadequate prenatal care unmanaged diabetes or high blood pressure Women over 35 are more likely to experience stillborn births Maternal Obesity; Obesity raises stillbirth risks Multiple pregnancy