Chapter 8-Nursing Care of Women with Complications During Labor

Chapter 8

Nursing Care of Women with Complications During Labor & Birth

While childbirth is a normal, natural event, sometimes factors affect the birth process

Obstetric Procedures

Induction or Augmentation Labor

• Induction is the initiation of labor before it begins naturally.
• Bishop scoring: 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 the Bishop score to determine a patient’s potential for successful induction.
• Augmentation is the stimulation of contractions after they have begun naturally.

Pharmacological & Mechanical Methods

Indications for Induction

Induction/Augmentation

Amniotomy: Complications & Nursing Care

Contraindications to Induction

Nonpharmacological Methods to Stimulate Labor

Augmentation: Complications & Nursing Care

Contraindications for Induction

Indications for Induction

1. Gestational hypertension
2. Ruptured membranes without spontaneous onset of labor
3. Infection within the uterus
4. Medical problems in the woman that worsen during pregnancy
5. Fetal problems such as slowed growth, prolonged pregnancy, or incompatibility between fetal and maternal blood types
6. Placental insufficiency
7. Fetal death

1. Placenta previa
2. Umbilical cord prolapse
3. Abnormal fetal presentation
4. High station of the fetus
5. Active herpes infection in the birth canal
6. Abnormal size or structure of the mother’s pelvis
7. Previous classic cesarean incision

VS

Nonpharmacologic Methods

• 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

Pharmacologic Methods

Oxytocin induction and the augmentation of labor

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
• Cervical softening assists with efforts to induce labor.
• Oxytocin does not have cervical ripening properties.

• Used to initiate or stimulate contractions
• Most commonly used method

Prostaglandin E1

Cytotec (Misoprostol) Administer PO (buccally or sublingual) or intravaginally More effective in achieving vaginal delivery within 24 hours Adverse effect: uterine tachysystole (hyperstimulation)

Prostaglandin E2

Cervidil (Dinoprostone) Administer intravaginally, sustained release

Mechanical Methods

Stripping amniotic membranes-involves separating the chorioamniotic membranes from the wall of the lower uterine segment. Transcervical balloon dilators-insert a 16-Fr catheter, 30-mL balloon inserted through the cervix and slowly inflated. The mechanical pressure dilates the cervix.

Amniotomy

Nursing Care

Complications

What is it?

• The artificial rupture of membranes
• Done to stimulate or enhance contractions
• Commits the woman to delivery
• Stimulates prostaglandin secretion

• FHR outside normal range (110 to 160 beats/min)
• Observe color, odor, amount, & character of amniotic fluid
• Temperature 38°C (100.4°F) >
• Green fluid

Prolapsed umbilical cord-Can occur with the gush of amniotic fluidInfection-Membranes no longer block vaginal organisms from entering the uterus Abruptio placentae-more likely to occur with the change in uterine size

Preparing for Augmentation

Safety Alert

Oxytocin is the most common method of labor induction or augmentation in women with a favorable cervix. There are differences in the amount used depending on whether it is an INDUCTION or AUGMENTATION. This is a high-alert medication!

Complications

Nursing Care

Augmentation of Labor

Be aware of increased uterine activity & monitor FHR q 15 min during active labor & q 5 min during transition.-Reposition woman to lateral position -Decrease dose to half the current rate or D/C -Prepare an IV bolus of LR -Administer oxygen 10 L/min -Prepare IV terbutaline for administration -Assess contractions and FHR q 5 min.

Most common complications are r/t overstimulation of the uterus are uterine rupture & fetal compromise. Blood flow is reduced when contractions are too long, frequent, or intense. Placental exchange occurs between contractions, and in this situation, that ability is reduced.Water intoxication can occur. Oxytocin inhibits urine excretion & promotes fluid retention. Most common with large doses and fluids given after birth.

• Obtain baseline vital signs and fetal heart rate
• Ensure IV line is placed
• Remains in bed for up to 2 hours
• Vitals measured q 30-60 min
• Temp taken q 2-4 h
• Monitoring I&O
• Assess for signs of uterine tachysystole
• Stop infusion with abnormalities in uterine activity or FHR

External Cephalic Version

The most common method of changing the fetal position. Done prior to 37 weeks gestation.

• Must have an NST or BPP done prior to determine fetal condition & adequate amniotic fluid
• Mother receives a tocolytic drug to relax the uterus & RhoGAM if indicated

An internal version is considered an EMERGENCY procedure!

Contraindications

• Disproportion between mother’s pelvis & fetal size
• Abnormal uterine/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 (internal version)

Episotomy

Lacerations

Controlled surgical enlargement of the vaginal opening during birth

1. Indications for episiotomy
1. Better control over where and how much the vaginal opening is enlarged
2. An opening with a clean edge rather than the ragged opening of a tear
2. Note: Perineal massage and stretching exercises before labor may be an alternative to an episiotomy.

Uncontrolled tearing of perineal tissue

1. First degree—superficial vaginal mucosa or perineal skin
2. Second degree—involves vaginal mucosa, perineal skin, and deeper tissues of the perineum
3. Third degree—same as second degree, plus involves anal sphincter
4. Fourth degree—extends through the anal sphincter into the rectal mucosa

VS

Nursing Care

• Cold packs to the perineum for at least 12 h to reduce pain, bruising, & edema
• After 12-24 h, warmth in form of heat packs, sitz baths increase circulation, comfort, & healing
• Provide oral analgesics

Extractions

Risks & Nursing Care

Vaccum

Forceps

• Cervix must be fully dilated, membranes ruptured, bladder empty, +2 station
• Trauma to maternal or fetal tissues
• Mother may have a laceration or hematoma in her vagina
• Infant may have bruising, facial or scalp lacerations/abrasions, cephalohematoma, or intracranial hemorrhage.

Uses suction applied to the fetal head so the physician can assist the mother’s expulsive efforts Used only with occiput presentation and at end of second stage of labor

Provides traction & rotation of the fetal head when the mother’s pushing efforts are insufficient to accomplish a safe delivery Used at end of second stage of labor in vaginal delivery Forceps may also help the physician extract the fetal head through the incision during a cesarean birth

Cesarean Section: Indications

• 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

Preparation for Cesarean Birth

Clinical lab studies to identify anemia and blood-clotting abnormalities

Baseline vital signs, including fetal heart rate

Foley catheter inserted

Place IV line

CBC, coagulation studies, blood typing

Low Transverse Incision

Types of Incisions

Skin

1. Vertical allows more room for a large fetus
2. Transverse

Uterine

1. Low transverse: not likely to rupture during another birth; VBAC possible with this type
2. Low vertical: minimal blood loss; more likely to rupture during another birth
3. Classic: rarely used; more blood loss; most likely to rupture during another pregnancy

Low Vertical Incision

Classic Incision

Risks

1. Risks r/t anesthesia

8. Scarring of the uterus

2. Respiratory complications

Risks to the Newborn

9. Inadvertent preterm birth

3. Hemorrhage

4. Blood clots

10. Respiratory problems r/t delayed aborption of lung fluid

5. Injury to the urinary tract

11. Injury, laceration or bruising

6. Delayed peristalsis (paralytic illeus)

7. Infection

Cesarean Section: Start to Finish

Nursing Care in the Recovery Room

• 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

Problems with the Pelvis and Soft Tissues

Risk Factors

Abnormal Labor

Called dysfunctional labor.Does not progress in terms of dilation, effacement, or descent of the fetus.

Problems with the Psyche

Problems with the Powers of Labor

Abnormal Duration of Labor

Problems with the fetus

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

Risk Factors

Hypertonic dysfunction

Hypotonic dysfunction

1. Increased muscle tone
2. Usually occurs during the latent phase of labor
3. Characterized by contractions that are frequent, cramplike, and poorly coordinated
4. Painful but nonproductive
5. Uterus is tense, even between contractions, leads to reduced blood flow to the placenta

1. Decreased muscle tone
2. Labor begins normally, but diminishes during active phase
3. More likely to occur if uterus is overdistended
4. Stretches the muscle fibers and reduces their ability to contract effectively

VS

Ineffective Maternal Pushing

• 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

Problems with the Fetus

Macrosomia—large fetus; weighs more than 4000 g (8.8 lb)

• May not fit through birth canal
• Can contribute to hypotonic labor dysfunction

Shoulder Dystocia

• Usually occurs when fetus is too large
• Is an emergency
• Fetal chest cannot expand
• Assess mother & newborn for injuries
• Mother may have torn perineal tissue
• More at risk for uterine atony & postpartum hemorrhage
• Uterus does not contract well after birth
• Infant may have fractured clavicle

Multifetal Pregnancy-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

Abnormal Presentation/PositionsDoes not pass easily Interferes with most efficient mechanisms of labor Can cause cord compression May require external version 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

Nursing Care for Abnormal Fetal Presentation or Positions

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

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

Problems with the Pelvis and Soft Tissues

Effects of Hormones Released

Most common factors that can increase stress

1. The uterus uses more glucose for energy.
2. Diverts blood from the uterus
3. Increases tension of pelvic muscles; can impede fetal descent
4. Increases perception of pain

1. Lack of analgesic control of excessive pain
2. Absence of a support person or coach
3. Immobility and restriction to bed
4. Lack of ability to carry out cultural traditions

Increased anxiety causes hormones to be released & reduces contractility of the smooth muscle

Abnormal Duration of Labor

Prolonged Labor

Friedman curve

Precipitate Birth

A birth that is completed in less than 3 hours Labor begins abruptly & intensifies quickly. Contractions may be frequent & 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

Prolonged labor can cause

• Maternal or newborn infection
• Maternal exhaustion
• Postpartum hemorrhage

Greater anxiety and fear

• Assist the woman to conserve her strength
• Providing encouragement

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

Preterm Labor: Some Risk Factors

• Exposure to DES (diethylstilbestrol)
• 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

Signs of Impending Preterm Labor

1. A shortened cervix on ultrasound at 20 weeks may be predictive of preterm labor.
2. Diagnosis of preterm labor is based on cervical effacement and dilation of more than 2 cm.
3. A fibronectin test
1. Fibronectin is a protein produced by the fetal membranes and leaks into vaginal secretions if uterine activity, infection, or cervical effacement occurs.
2. The presence of fibronectin in vaginal secretions between 22 and 24 weeks gestation is predictive of preterm labor.

Maternal Symptoms of Preterm Labor

• 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 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”

Premature Rupture of Membranes (PROM)

• 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

1. Report a temperature that is above 38°C (100.4°F)
2. Avoid sexual intercourse or insertion of anything into vagina
3. Avoid orgasms
4. Avoid breast stimulation
5. Maintain any activity restrictions prescribed
6. Note any uterine contractions, reduced fetal activity, and other signs of infection
7. Record fetal kick counts daily and report fewer than 10 kicks in a 12-hour period

Patient Teaching for a Woman with Infection or in Preterm Labor

Tocolytic Therapy

• Goal is to stop uterine contractions
• Keep fetus in utero until lungs are mature enough to adapt to extrauterine life
• Magnesium sulfate (IV), beta-adrenergic (PO), calcium channel blockers (PO)
• Prostaglandin synthesis inhibitors

Contraindications:

• Preeclampsia
• Placenta previa
• Abruptio placentae
• Gestational age over 37 weeks
• Chorioamnionitis
• Fetal demise

Tocolytics

Magnessium Sulfate

B-Adrenergic Drugs

Calcium Channel Blockers

Prostaglandin Synthesis Inhibitors

Drug of choice; not very effective, but protects from cerebral palsy.

• Vitals done hourly
• If fetus is born <2 h from dose, notify nursery staff
• Monitor for respiratory rate & lung sounds, S/S fluid overload, urine output, DTR, & bowel sounds

Terbutaline most common; given subq to stop contractions within minutes

• Monitor for increased HR & BP
• Nasal stuffiness & hyperglycemia can occur

Indomethacin-Not as commonly used

• Causes a reduction in amniotic fluid
• Requires CLOSE fetal monitoring as it can prematurely close the ductus arteriosis causing fetal death

Nifedipine (Procardia) most commonly used to stop contractions Causes vasodilation:

• Maternal flushing
• Hypotension
• Monitor BP & HR closely

Do NOT use with Magnesium Sulfate Use cautiously in women with hypotension

Stopping Preterm Labor

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.

Prolonged Pregnancy

• Lasts longer than 41 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

Nonstress tests (NST)

Tests Used to Confirm the Diagnosis of Prolonged Pregnancy

Amniotic fluid index (AFI)

Any pregnancy lasting longer than 41 weeks must be monitored closely for

Biophysical profile (BPP)

Kick counts

Emergencies During Childbirth

Uterine rupture

Placenta accreta

Prolapsed umbilical cord

Complete-hole in uterine wall into abdominal cavity Incomplete-tears into a nearby structure, such as ligament, but not all the way into the abdominal cavity Dehiscence-old uterine scar separate Characteristics of Uterine Rupture

• Shock caused by bleeding into the abdomen
• Abdominal pain
• Pain in the chest, btw the scapulae 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

Complete: The cord is visible at the vaginal opening. Palpated: The cord cannot be seen but can be felt as a pulsating structure when a vaginal examination is done. Occult: The prolapse is hidden and cannot be seen or felt; it is suspected based on abnormal fetal heart rates.

Common with mothers who have had a previous C-section delivery, fibroids, increased maternal age, or endometrial defects Symptoms include profuse bleeding at attempts to manually deliver the placenta after the fetus is delivered.

Amniotic Fluid Embolism

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

Treatment

• Mechanical ventilation
• Treat shock with electrolytes and volume expanders
• Replace coagulation factors such as platelets and fibrinogen
• PRBC sometimes provided
• I&O monitored closely
• Pulse oximetry
• Cardiac monitoring
• Transfer to ICU

AFE

A serious complication of childbirth Prompt identification of the phenomenon is required to save the woman’s life.