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High Risk Labor and Births Chapter 21

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Title: High Risk Labor and Births Chapter 21


1
High Risk Labor and BirthsChapter 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 708-714

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 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 21.2 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

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 0 1 2 3
Dilatation 0 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 21.2 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 30-60 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

37
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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

46
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47
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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

70
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73
Shoulder Dystocia
  • Shoulder Dystocia simulation
  • Shoulder Dystocia delivery
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