c

         



   




 
    ± rare complication of pregnancy characterized by the
sudden, acute onset of hypoxia, hypotension, or cardiac arrest and coagulopathy that can occur either
during labor and during birth, or immediately after birth; also known as amniotic fluid embolism



  
  ± medications administered to the mother for the purpose of accelerated to the
mother for the purpose of accelerating fetal lung maturity when an increased risk exists for preterm birth
24-34 weeks of gestation



     ± stimulation of ineffective UCs after labor has started spontaneously but is not
progressing satisfactorily


  ± Rating system to evaluate inducibility (ripeness) of the cervix; a higher score increases
the likelihood of a successful induction of labor



 


 - condition in which the infant¶s head is of such a shape, size, or
position, that it cannot pass through the mother¶s pelvis, or maternal pelvis is too small, abnormally
shaped, or deformed to allow the passage of a fetus of average size

  
± birth of a fetus by an incision through the abdominal wall and uterus

  
 ± inflammatory reaction in fetal membranes to bacteria and viruses in the amniotic fluid,
which then become infiltrated with polymorphonuclear leukocytes


     ± abnormal UC that prevent normal progress of cervical dilation, effacement, or
descent


 ± prolonged, painful, or otherwise difficult labor caused by various condition associated with
the five factors affected by labor (powers, passage, passenger, maternal position, and maternal emotions)

!"!#
 
   ± turning of the fetus to a vertex presentation by external exertion of
pressure on the fetus through the maternal abdomen

 
$ 

± vaginal birth in which forceps are used to assist in the birth of the fetal head

%

&

  ± uncoordinated, painful, frequent UCs that do not cause cervical
dilation and effacement; primary dysfunctional labor

%

&

  ± weak, ineffective UCs, usually occurring in the active phase of labor,
often r/t cephalocaudal disproportion or malposition of the fetus; secondary uterine inertia




± Birth that occurs between 34 and 36 weeks of gestation

'#
± hormone produced by the posterior pituitary gland that stimulates UC and the release of milk
in the mammary glands (let-down reflex); synthetic oxytocin is a medication that mimics uterine
stimulating action of oxytocin

 
$(  ± Pregnancy past 42 weeks



   rapid or sudden labor lasting less than 3 hours from the onset of UC to complete
birth of the fetus


'c ± rupture of amniotic sac and leakage of fluid before the onset of labor at any
gestational age



± Birth occurring before the completion of 37 weeks of gestation


   ± UC causing cervical change that occurs between 20 and 37 weeks of pregnancy

(
'c ± premature ROM that occurs before 37 weeks of gestation


 
 &   ± protrusion of the umbilical cord in advance of the presenting part

 
 ± condition in which the head is born, but the anterior shoulder cannot pass under the
pubic arch

( 


± administration of analgesics and implementation of comfort or relaxation measures
to decrease pain and induce rest for management of hypertonic uterine dysfunction

(  
 ± medications used to suppress uterine activity and relax the uterus in cases of
hyperstimulation or preterm labor

('$(     ± period of observation to determine whether a laboring woman is likely to be

successful in progressing to a vaginal birth

" $

± birth involving attachment of vacuum cap to the fetal head (occiput) and
application of negative pressure to assist in the birth of the fetus

" ± Vaginal birth after cesarean ± giving birth vaginally after having had a previous cesarean birth

!(!c')(%

preterm labor defined as cervical changes and UCs occurring 20 weeks ± 37 weeks of pregnancy
preterm birth ± any birth that occurs before completion of 37 weeks gestation
rate increasing for the last several years, major unsolved problem in perinatal medicine today

approximately 75% of preterm births are considered late preterm births (occurring between 34-36 weeks)

majority of infant deaths, and most serious morbidity occur 16% infants born before 32 weeks gestation

!(!c)(% *'+)(%+!),%(

preterm birth describes LENGTH of gestation (less than 37 weeks, regardless of weight)
low birth weight describes only WEIGHT at the time of birth (<2500g)
Preterm birth ü more dangerous health condition because a decreased time in utero correlates with
immaturity of body systems.
low birth weight babies can be, but are not necessarily preterm

LBW babies can be caused by conditions such as; IUGR, condition of inadequate fetal growth, not
necessarily correlated w/ initiation of labor
infants born at a preterm gestation can be more than 2500g at birth

Increased used of reproductive technologies has led to a rise in multifetal gestations

Willingness of health care providers to end pregnancy when conditions threaten health of mother or fetus
after 32-34 weeks also contributes to rise in preterm births





 - )




  ± occur after early initiation of labor process

approximately 75% of all preterm births are spontaneous

conditions ± preterm labor w/ intact ROM, preterm premature ROM, cervical insufficiency, or amniotitis
often result in preterm birth

 #$./ 
 

 


-genital tract infection
-non-caucasian rce
-multifetal gestation
-2nd trimester bleeding
-low pregnancy weight
-history of previous spontaneous preterm births

)
- occur as a means to resolve maternal or fetal risk related to continuing pregnancy
25% are indicated because of medical or obstetric conditions that affect the mother, fetus, or both
increase in the number of indicated preterm births account for much of the recent rise in late preterm
births

 #$    




-preeclampsia
-fetal distress
-IUGR
-abruptio placentae
-intrauterine fetal demise
-pregestational or gestational diabetes
-renal disease
-Rh sensitization
-congenital malformalities




 
   

*history of previous preterm birth, multiple gestation, bleeding after 1st trimester, and low maternal BMI
major risk factors for sponatenous preterm birth
others: non-caucasian, low SES and educational status, living with chronic stress, smoking, substance
abuse, physically demanding work conditions, periodontal disease

*because at least 50% of all women who give birth prematurely have NO identifiable risk factors«
women should be educated about prematurity early, also in preconceptional period

     ± Fetal fibronectin

diagnostic test for preterm labor.
fetal fibronectin is a glycoprotein found in plasma produced during fetal life.
collection of fluid from cervix and vagina using a swab during vaginal examination
normally present in cervical and vaginal fluid early in pregnancy, and again in late pregnancy
presence during the late 2nd and early 3rd trimesters may be related to placental inflammation, which is
thought to be one cause of spontaneous preterm labor.
not sensitive though, before 35 weeks gestation, predicts only 25% of the time.
**This test is better to predict who will NOT go because preterm birth is very unlikely if this marker is
negative
use in women who are low-risk is not recommended

  
±
changes in cervical length occur before UA
women whose cervical length is more than 30mm are UNLIKELY to give birth prematurely, even if they
have sx

 ± Infection is the only factor that has been definitely shown to cause preterm labor
bleeding at the placental implantation site in 1st or 2nd trimester ± possible
resulting uteroplacental ischemia or hemorrhage at the decidual layer of the placenta may somehow
activate the preterm labor process

Intrauterine inflammation is associated with infection, uterine vascular compromise, decidual hemorrhage
ü may contribute to preterm labor

Maternal/Fetal stress, uterine overdistention. allergic reaction, decrease in progesterone may play a part

*Multiple pathological processes then cause UC, cervical changes, or ROM

2 recent studies ü recurrent preterm birth can be prevented in some women (who have previously given
birth prematurely ONLY) by administering prophylactic progesterone supplementation (1 vaginal, 1 IM
weekly)
risk of preterm reduced by 1/3
? how much is needed ü further studying.

 
 

address risk factors associated with preterm labor and birth
*health promotion, disease prevention
healthy lifestyles, especially child-bearing ages
preconceptional counseling w/ hx of preterm birth
smoking cessation has been shown to prevent preterm labor and birth
*more studies needed« rates increasing

!  
 0  

although often not preventable, early recognition is essential to reduce neonatal morbidity and morality
Interventions : transfer of mother before birth to hospital equipped to take care of preterm infant, ABX to
prevent neonatal group B Strep, antenatal corticosteroids to prevent or reduce neonatal morbidity or
morality from conditions including respiratory distress syndrome, intraventricular hemorrhage, and
necrotizing enterocolitis

*Education regarding symptoms of UC or cramping between 20 and 37 weeks of gestation need to be

directed toward explaining these are not normal discomforts, but rather possible preterm labor sx



 #$12# 
  
&

 

- UC that occur more frequently than every 10 minutes, persisting for 1 hour or more
-UC that may be painful, or painless

  

-lower abdominal cramping, similar to gas pains; may be accompanied by diarrhea
-dull, intermittent low back pain (below the waist)
-painful, menstrual like cramps
-suprapubic pain or pressure
-pelvic pressure or heaviness
-urinary frequency

"   
-change in character and amount of usual discharge; thicker (mucoid) or thinner (watery); bloody, brown,
or colorless; increased amount; odor
-rupture of amniotic membranes

   

    1 3   

 
1. Gestational age between 20 and 37 weeks
2. Uterine Activity (UCs)
3. Progressive cervical changes (effacement of 80%, or cervical dilation of 2 cm or greater)

If fetal fibronectin is used as another diagnostic criteria, a sample of cervical mucus for testing should be
obtained before an examination for cervical changes because lubricant can reduce the accuracy of the test
for fetal fibronectin

+

 

 

   
-empty your bladder
-drink 2-3 glasses of water or juice
-lie down on your side for 1 hour
-palpate for contractions
-if sx continue, call your PCP, or go to hospital
-if sx go away, resume light activity but not what you were doing before sx occurred
-if sx return, call your PCP, or go to hospital

$  
  4 -  )cc!)(!5

-UC every 10 minutes or less for 1 hour or more
-Vaginal bleeding
-Odorous vaginal discharge
-Fluid leaking from the vagina


)/!(5!c')/)()'


 


 
commonly prescribed intervention for prevention of preterm birth
*bed rest should not be routinely recommended
has many adverse physical effects, risk of thrombus formation, muscle atrophy, osteoporosis, and CV
deconditioning, also effects psychologically, emotionally, socially, and financially
"!!!//!('/!!(
c
 
6  7
-weight loss
-muscle wasting, weakness
-bone demineralization and calcium loss
-decreased plasma volume and cardiac output
-increased clotting tendency, risk for thrombophlebitis
-cardiac deconditioning
-alteration in bowel function
-sleep disturbances, fatigue
-prolonged postpartum recovery

c
 !
6   7
$loss of control associated w/ role reversal
-dysphoria-anxiety, depression, hostility, anger
-guilt associated w/ difficulty complying with activity, restriction and inability to meet the responsibilities
-boredom, loneliness
-emotional lability (mood swings)

!
 




-stress associated w/ role reversal, increased responsibilities, disruption of family routines
-financial stress associated w/ loss of maternal income, and cost of treatment
-fear and anxiety regarding the well-being of the mother and fetus



  #  
 


frequently recommended for women at risk for preterm birth
has not been shown effective at preventing
sexual abstinence has been studied in women w/ specific risk factors, such as short cervix
*more research indicated.
However, if sx of preterm labor occur after sexual activity, that activity may need to be curtailed until
after 37 weeks

%  
³taking it easy´ at home for a few week or months.
nurse can help with women and family to deal with many difficulties
keep items needed within reach (tv, radio, tapes, computer w/ internet, snacks, books, magazines, and bed
near window or bathroom is helpful)
egg crate cover may be comfortable
daily schedule of meals, activities, hygiene, and grooming helps w/ boredom, and maintains control and
normalcy



  &

 


 
 are medications given to arrest labor after UC and cervical change have occurred
usually will not prolong long enough for full fetal development, growth or maturation, to take place
*goal ± to delay long enough for interventions to reduce neonate mobidity and morality

medication choice depends on effectiveness, risks, s/e

no medications are FDA approved, but used on an ³off-label´ basis
 #$8'())()'('(''5)
c
 
HTN, significant vaginal bleeding, cardiac disease
/

gestational age of 36 weeks or more, fetal demise, lethal fetal anomaly, chorioamnioitis, evidence of acute
or chronic fetal compromise

 #$9  4  
 




-explain purpose and side effects
-position women on their sides to enhance placental perfusion and reduce pressure on cervix
-monitor maternal VS, FHR, and labor status according to policies
-assess mother and fetus for sx of adverse reactions r/t tocolytic meds.
-determine maternal fluid balance by measuring daily weight and I&O
-limit fluid intake to 2500-3000 mL / day, especially if beta-adrenergic agonists is used
-provide psychosocial support and opportunities for women and family to express feelings
-offer comfort measures as necessary
-encourage diversional activities and relaxation techniques

:c 
 most commonly used

clinicians familiar w/ its use and treatment of preeclampsia and its presumed safety as compared to Beta
adrenergic agonists
given IV, good choice when other tocolytics are contraindicated
relaxes smooth muscle my competing with calcium in the cells

Beta2adrenergic agonists have been widely used

many maternal/fetal cardiopulmonary and metabolic a/e
being replaced
should not be used with pts known or suspected heart disease, severe preeclampsia, or eclampsia,
pregestational or gestational diabetes, or hyperthyroidism

(
6
7 ± best known beta-adrenergic agonist

relaxing uterine smooth muscle as a result of beta2 receptors on uterine smooth muscle
SC given to help diagnose preterm labor
in studies where contractions persisted or recurred were more likely to be in preterm labor than those
whose contractions ceased
used for maternal transfer, or when another slower onset of action medication is being administered
concurrently


± calcium channel blocker, can suppress contractions
inhibits calcium from entering the smooth-muscle, thus reducing UCs
ease of administration, and low incidence of a/e, its use is increasing
maternal s/e ± headache, flushing, dizziness, nausea ± mild
relate to hypotension
1 MI has been reported who received 2nd dose
*CANNOT be combined with MG, or immediately after beta-mimetics

) 
6) 7 ± a NSAID has been shown in some trials to suppress preterm labor by blocking
production of prostaglandins
serious maternal side effects Uncommon
3 serious s/e cause major concerns
-constriction of ductus arteriosus, oligohydramnios, and neonatal pulmonary hypertension
* use in short duration

 :
  

± each woman should be assessed in their knowledge of:
-dangers of preterm birth
-sx of preterm birth
-what to do if sx occur

;
-psychosocial status
-emotional status
-impact of diagnosis and treatment on family dynamics

  ;
-risk for imbalanced fluid volume (maternal) r/t: the administration of tocolytics to suppress preterm labor
-interrupted family processes r/t: required limitation on maternal activity associated with preterm labor
-anticipatory grieving r/t: potential for birth of the preterm infant
-risk of impaired parent-infant attachment r/t: care requirements of preterm infant

!#

'
  ±
learn s/sx of preterm labor, be able to assess herself, and her need for intervention
follow teaching suggestions, call PCP if sx occur
not experience sx of preterm labor, if occurs able to take action
maintain pregnancy for at least 37 weeks
give birth to a healthy, full-term infant

   0)
 
 

teach sx of preterm labor
teach appropriate responses if preterm labor does occur
administer medications as ordered
assist women and family to make lifestyle modifications if necessary to decrease risk
assist in making plans to transport the pregnant woman-fetus to a hospital if sx appear
prepare to assist w/ stabilization and initial care of preterm infant if birth appears imminent


PROMOTION OF LUNG MATURITY

Antenatal glucocorticoids
given as IM injection to the mother to accelerate fetal lung maturity * for preventing morbidity and
morality
reduce significantly the incidence of respiratory distress syndrome, IV hemorrhage, necrotizing
enterocolitis, and death in neonates w/o increasing the risk of infection to mother or newborn
NIH recommends all women 24-34 weeks gestation be given a single course when preterm is threatened,
unless corticosteroids will have an adverse effect on mother or birth is imminent.
*Optimal benefit begins 24 hours after injection

:
 : stimulates lung maturation by promoting release of enzymes that induce production of lung
surfactant (NOT FDA approved)
:)
 : accelerate lung maturity in fetuses 24-34 weeks
:  0 
;Bethamethasone ± 12 mg IM for 2 doses, 24 hours apart
Dexamethasone: 6 mg IM for 4 doses, 12 hrs apart

  
 

pulmonary edema (if given w/ beta adrenergic meds)
may worsen maternal conditions (diabetes, hypertension)


give deep IM injection in gluteal muscle
teach signs of pulmonary edema
assess blood glucose levels and lung sounds

c  
 ) 




labor that is 4cm or greater is likely to lead to inevitable preterm birth
*remember women in preterm birth progress rapidly to birth that a very small fetus may be born through a
cervix not completely dilated
malpresentation occurs more frequently
providers skilled in resuscitation

Fetal and Early Neonatal Loss

-preterm birth or the presence of congenital anomalies or genetic disorders incompatable with life are
major reasons for intrauterine fetal demise (still birth) or early neonatal death
sometimes parents prepared, or sometimes unexpected
*must be prepared to provide sensitive care to patients and families

if known previously, discussion needs to be made

C-section if abnormal FHR occurs
& if C-section not desired, FHR will not be monitored during labor

whether to attempt resuscitation or not, and to what length should this go

sometimes feasibility is not known until born
baby too small, too immature, too malformed for effective resuscitation, comfort care instead
baby should be kept warm, comfortable, and depending on wishes, bedside or in nursery
parents can choose to view and hold baby as they wish
after birth ± women should be given opportunity to stay on unit, or moved to another hospital unit
may not want to hear babies crying, and see healthy babies
but, postpartum care and grief support probably best where staff is not experienced


'c
spontaneous rupture of the amniotic sac and leakage of amniotic fluid beginning before the onset of labor
at any gestational age



'c
membranes rupture before 37 weeks is responsible for 1/3 of all preterm births
Preterm PROM most likely from pathologic weakening of fetal membranes, caused from inflamm, stress
from UC, or other factors causing increase in uterine pressure
diagnosed when woman feels gush of fluids, or slow leak from vagina

Chorioamniotitis ± (infection of the amniotic cavity)

most common maternal complication of preterm ROM
others ± placental abruption, sepsis, and death
fetal complications ± primarily r/t intrauterine infection, umbilical cord compression, and placental
abruption
another complication ± before 20 weeks ± pulmonary hypoplasia

at term ± infection is greater risk, birth is best option

otherwise weigh out options of infection, vs. maternal, and fetal risk

usually hospitalized to try to prolong pregnancy and allow time for fetal maturity
unless ± intrauterine infection, significant vaginal bleeding, placental abruption, preterm labor, or fetal
compromise

 
   
of preterm PROM ± daily fetal assessment, usually by non-stress test, and
biophysical profile BPP, monitored for labor, placental abruption, development of intrauterine infection
antenatal corticosteroids given to women less than 32 weeks given they have been proven to decrease the
risk of several neonatal complications, resp distress syndrome, Iv hemorrhage, and necrotizing
entercolitis.
also 7 days ABX broad spectrum to treat or prevent intrauterine infection

 
  major part of nursing care and patient education after preterm PROM

keep genital area clean, nothing introduced into vagina

signs of infection (fever, foul-smelling vaginal discharge, rapid pulse) reported immediately
if transferred, tocolytics may be given to gain time transporting, or for antenatal steroids or ABX to reach
effective levels

c  

-take temp q 4 hours
-report temp more than 38C (100.4)
-remain on modified bed rest
-insert nothing into vagina
-do not engage in sexual activity
-assess for UC
-do fetal movement count daily
-do not take tub baths
-watch for foul-smelling vaginal discharge, or if uterus becomes tender or sore when touched
-wipe front to back after urinating or bowel movement
-take ABX
-see PCP as scheduled

5(')
long, difficult, or abnormal labor ; dysfunctional labor, or dystocia
caused by various conditions associated w/ 5 factors
occurs 8-11% of all births
*2nd most common indication for c-section, after previous cesarean birth

   
  4;

-ineffective UC or maternal bearing down efforts, the most common cause*
- alterations in pelvic structure (passage)
-fetal causes that include abnormal presentation or position, anomalies, excessive size, number of fetuses
(passenger)
-maternal position during labor and birth
-psychologic responses of the mother to labor related to past experiences, preparations, culture and
heritage, and support system

5 factors are interdependent

Dystocia ± expected when the characteristics of UCs are altered, or when progress in the rate of cervical
dilation or progress in fetal descent and expulsion is lacking

5/&()''

described as abnormal UC that prevent the normal progress of cervical dilation, effacement (primary
powers), or descent (secondary powers)

/ 
  
    ;
-overweight
-short
-advanced maternal age
-infertility difficulties
-uterine abnormalities (congential malformations, overdistention, as w/ multiple gestation, or
polyhydramnios)
-malpresentations and positions of fetus
-cephalopelvic disproportion (fetopelvic disproportion)
-uterine overstimulation w/ oxytocin
-maternal fatigue, dehydration, electrolyte imbalance, fear
-inappropriate timing of analgesic or anesthetic administration

Abnormal activity ± hyper or hypo

Contractions ± frequent, painfully strong, w/ hypertonic uterine activity, but ineffective at promoting
cervical effacement, and dilation

Hypotonic ± rise in uterine pressure generated during contractions is insufficient to promote cervical
dilation and effacement

%

&

  ± (primary dysfunctional labor)
anxious, 1st time mother,
contractions in latent stage (cervical dilation <4cm) and usually uncoordinated
uterus may not relax between contractions
contractions in the midsection of the uterus, unable to put pressure on cervix

exhausted, loss of control from intense pain, and lack of progress

*therapeutic rest ± warm bath or shower, and morphine, Demerol, or ambient, to inhibit UC, reduce pain,
encourage sleep *

%

&

 $ *more common type (secondary uterine inertia)
normal progress into active phase, then contractions become weak and ineffective, or stop all together
insufficient for effacement and dilation

Cephalopelvic disproportion and malposition are common causes

exhausted, increased risk of infection

Management ± insertion of IUPC to evaluate UA.
labor is augmented with oxytocin if contractions are not strong enough to cause cervical change
   4 ± (bearing ±down efforts)
compromised when large amounts of analgesics are given.
may block the bearing-down reflex, alter the effectiveness of voluntary efforts
exhaustion from lack of sleep, long labor, fatigue from inadequate hydration and food intake can decrease
effectiveness of women¶s voluntary efforts.
maternal position can work against the forces of gravity, and decrease strength and efficiency of the
contractions

nursing
help woman find comfortable position for pushing, coaching her to push effectively
assisted vaginal birth using vacuum or forceps or cesarean birth will be necessary

    



1) prolonged latent phase
2) protracted active phase dilation
3) secondary arrest, no change
4) protracted descent
5) arrest of descent; no change
6) failure to descent

variety of causes: ineffective UCs, pelvic contractures, cephalopelvic disproportion, abnormal fetal
presentation, early use of analgesics, nerve block anesthesia, anxiety, stress.
chart on partogram, compare with intervals of normal labor times of nulli or multi, notify PCP

( $.    




    
  c

 
Prolonged Latent Phase > 20 hrs >14 hrs
Protracted active phase dilation <1.2cm/hr <1.5cm/hr
Secondary arrest, no change >2 hr > 2 hr
Protracted descent < 1cm/hr <2cm / hr
Arrest of descent; no change >1hr > ½ hr
Failure to descent No change during deceleration phase and 2nd stage
Precipitous Labor > 5 cm / hr 10 cm / hr




  
labor that lasts less than 3 hours from onset of contractions to time of birth
abnormal labor occurs in 2% of births
not usually associated w/ significant maternal or infant morbidity or morality

may result from hypertonic UC that are titanic in intensity

conditions ± placental abruption, excressive # of UC, recent cocaine use
maternal complications ± uterine rupture, lacerations of birth canal, ASP (anaphylactoid syndrome of
pregnancy (amniotic fluid embolism)) , and postpartum hemorrhage
fetal complications ± hypoxia, caused by decreased periods of uterine relaxation between contractions,
rare ± intracranial trauma r/t rapid birth



  



Pelvic Dystocia ± can occur whenever contracture of the pelvic diameter occur that reduce capacity of the
body pelvis, inlet midpelvis, outlet, or any combo of these planes
from congential abnormalities, neoplasms, maternal malnutrition, past trauma or MVA, immature pelvic
size ± adolescents

 
$(
 
obstruction of birth passage by an anatomic abnormality other than the bony pelvis
placenta previa (low lying placenta) that partially obstructs that internal os of the cervix
leiomyomas (uterine fibroids) in the lower uterine segment, ovarian tumors, a full bladder or rectum, may
prevent the fetus from entering the pelvis.
cervical edema can occur during labor when cervix is caught between presenting part and symphysis
pubis, or when woman begins bearing down efforts prematurely, inhibiting complete dilation
STDS ± (HPV) can alter cervical tissue integrity and thus interfere w/ adequate effacement and dilation

/
 

anomalies, excessive fetal size, malpresentation, malposition, or multifetal
complications ± neonatal asphyxia, fetal injuries / fx, maternal vaginal lacerations.
forceps assisted, vacuum assisted, or c-section may be necessary

  
gross ascites, large tumors, open neural tube defects, hydrocephalus can cause dystocia
anomalies affect the relationship of the fetal anatomy to the maternal pelvic capacity, interfering with
ability of fetus to descend through birth canal



 


 
  /

 


 
disproportion between the size of the fetus, and the size of the mother¶s pelvis
fetus cannot fit through the pelvis to be born vaginally
often CPD is related to excessive fetal size (macrosomia) (4000g or more), but often malposition is the
case
!
! can be associated with maternal diabetes, obesity, multiparity, large size of one or both
parents
maternal origin- when maternal pelvis is too small, abnormally shaped, deformed
unfortunately CPD cannot accurately be predicted

c 

 
-most common fetal malposition is persistent occiptoposterior position (right occipitoposterior or left
occipitoposterior) occurring in 15% of labors during latent phase of 1st stage of labor
5% are in this position in 2nd stage
labor prolonged *especially in 2nd stage
** Severe Back Pain from the head pressing on sacrum

 #$<   '


 
  
 
Measures to Relieve Back Pain and Facilitate Fetal Head Rotation

 

Counterpressure ± apply fist or heel of hand to sacral area
Heat/Cold ± apply to sacral area
Double Hip Squeeze ± knee chest position, partner or nurse places hands over gluteal muscles, presses
with palms and hands up and inward toward the pelvis
Knee Press ± sitting position w/ knees a few inches apart, feet flat on floor or stool
partner or nurse cups a knee in each hands, presses knees straight back toward the woman¶s hips while
learning forward toward the woman
/ 



  /
% 
-lateral abdominal stroking ± stroke abdomen in direction the head should rotate
-all 4¶s
-squatting
-pelvic rocking
-stair climbing
-lie on side which fetus should turn
-lunges ± in the direction of occiput

c 


 
commonly reported complication
breech most common 3-4% of labors

1) frank ± w/ hips flexed, knees extended

2) complete ± hips and knees flexed
3) footling breech ± one foot (single footing) or both (double footing) present before the buttocks

associated w/ multifetal gestation, preterm birth, maternal anomalies, hydramnios, and oligohydramnios
genetic disorders
neuromuscular disorders ± b/c they have less ability to move in utero
diagnosis ± made by palpation, and vaginal examination, usually confirmed by US

Vaginal ± safe can be done with experience, judgement, and skill

frank or complete, normal pelvis, flexed head, estimated fetal weight 2000 to 3800 g
if ECV is unsuccessful -- > can do C-section

risk for head being stuck after body is delivered (especially in footling
prolapse of umbilical cord

C-section usually for shoulder presentation

c

 

account for 3% of births
increased attributed to fertility enhancing drugs and procedures
35 or older more likely to have twins
increased risk for complications, and perinatal morality
ü stem from low birth weights, IUGR, preterm birth, placental dysfunction, cord prolapse
risk for CP higher in infants part of multiple birth
congential anomalies, and abnormal presentations can result in dystocia

maternal positioning, oxytocin, epidural anesthesia, forceps, vacuum

c-section usually for higher-order multiple births
each infant has own member of team

emotional support, expression of feelings, full explanation of events ü reduce anxiety and stress

 
  +  

functional relationship of UC, fetus, mother¶s pelvis altered by maternal position
using gravity, body-part relationships
*upright position in 2nd stage is associated w/ shorter interval, less pain, less perineal damage, less
operative vaginal births
discouraging movement or restricting labor to the recumbent or lithotomy position may compromised
progress
incidence of dystocia increase when women confined to positions
increased need for vacuum or forceps, or c-section

  

hormones, and NT released in response to stress ( catecholamines) can cause dystocia
stress, pain, absesnce of support, confinement to bed or restriction of movement
anxiety is excessive, inhibit cervical dilation, prolonged labor, increased pain
increased stress level hormones released ± betaendorphin, adrenocorticotropic hormone, cortisol,
epinephrine) cause dystocia by reducing UCs

   
 

 
-document all assessment findings, interventions, patient responses in the patient¶s record according to
policy
-assess whether woman and family is fully informed about the procedures she is giving consent to
-provide full explanations regarding events that are taking place and interventions that are needed to help
mom and baby
-maintain safety by administering meds and treatments correctly
-have telephone orders signed ASAP
-provide care at acceptable standards
- if short staffing occurs ± nurse should document that rejecting this additional assignment would have
placed patients in danger as a result of abandonment
-maternal and fetal monitoring continues until birth, according to policies, even when decision to carry
out c-section is made

" 
turning of fetus from one presentation to another
externally, or internally by physican

!"!#
 
  
used in attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth
it may be attempted in a labor and birth setting after 37 weeks
exertion of gentle, constant pressure on abdomen
US needs to be done 1st to determine position, rule out placenta previa, evaluate the adequacy of maternal
pelvis, assess the amount of amniotic fluid, gestational age, presence of anomalies
NST performed to confirm well being, FHR monitored
informed consent obtained
A tocolytic agent often given to relax the uterus to facilitate maneuver.
Contraindications ± Uterine anomalies, 3rd trimester bleeding, multiple gestation, oligohydramnios,
evidence of uteroplacental insufficiency, nuchal cord, previous c-section, obvious CPD

*Most successful in multiparous woman who has normal amount of amniotic fluid, whose fetus is not yet
engaged.
IF EVC not successful, recommendation for C-Section
during ± nurse continuously assesses FHR (esp. for brady, or variable decels), maternal VS, comfort,
uterine activity, and vaginal bleeding
FHR continue for 1 hour
Women who are RH- should receive RH (D) immune globulin because manipulation could cause
fetomaternal bleeding
)
 " 
physician inserts hand into uterus and changes presentation to cephalic (head) or podalic (foot)
rarely used ±
sometimes in twin pregnancies to help deliver the 2nd fetus
safety is not documented, fetal injury is possible
C-section is usual method for managing malpresentation
*nurse ± monitor status of fetus, support woman

)
    

chemical or mechanical initiation of UCs before their spontaneous onset for the purpose of bringing about
the birth
induced either electively, or for indicated reasons
Number of induced has doubled to 22.3%
elective is increasing more than indicated

induction of labor is indicted if continuing pregnancy could be dangerous for mother or fetus, and if no
contraindications exist to artificial ROM or augmenting UCs.

elective ± w/o a medical condition

convenience?
when specific people are there to handle complications

2 major risk factors

increased rate of c-section births
Iatrogenic prematurity ± to prevent, elective induction should not be done before 39 weeks

 #$=)
   
 
    )
 

)
 
-HTN complications of pregnancy
-fetal death
-chorioamniotis
-dm
-postterm pregnancy, especially w/ oligohydramnios
-IUGR
-premature PROM w/ established fetal maturity

 
 
 

-acute, severe fetal distress
-shoulder presentation (transverse lie)
-floating fetal presenting part
-uncontrolled hemorrhage
-placenta previa
-previous uterine incision that prohibits a trial of labor


  
 
 

-grand multiparity (5 or more pregnancies that ended after 20 weeks)
-multiple gestation
-suspected CPD
-breech
-inability to adequately monitor FHR or contractions, or both
IV oxytocin and amniotomy are most common methods to induce labor
misoprostol vaginally has proven to be more effective for cervical ripening
herbal preps ( raspberry leaves, blue or black cohosh, evening primrose oil)

Success rates are increased when the condition of the cervix is favorable, or inducible

 ± can evaluate inducilibility
when it is 8 or more, induction is more successful

)%''!
Dilation (cm) o 1-2 3-4 >5
Effacement 0-30 40-50 60-70 >80
Station -3 -2 -1,0 +1,+2
Cervical Consistency firm med soft soft
Cervix Position post mid-post ant ant

  

prostaglandin E1 and E2 shown to be effective before induction to ³ripen´ (soften, and thin) cervix
advantage ± decrease need for oxytocin, decreased oxytocin induction time, decrease in amount
*E1 though less expensive, and more effective«. increased risk for hyperstimulation of uterus with FHR
changes and meconium-stained amniotic fluid

c   ± dilators ripen by stimulating the release of endogenous prostaglandins

Balloon catheters can be inserted into the intracervical opening to ripen and dilate

% 

 (substances that absorb fluid from surrounding tissues and then enlarge) can be
used

Laminaria tents ± made from desiccated seaweed

Synthetic dilators containing Mg Sulfate (Lamicel)

absorb fluid, expand and cause cervical dilation

achieved lower rate of birth within 24 hours ±no increase in c-section, no hyperstimulation

Others: breast stimulation, intercourse, ingestion of castor oil, stripping membranes

not been proven to be effective, and safe or undesirable side effects.


 ± (artificial rupture of membranes) can be used to induce labor when the condition of the
cervix is favorable (ripe) to augment labor if progress begins to slow
amniotomy decreases the length of some labors, even w/o oxytocin
risks ± itnraamniotic infection, variable FHR decelerations
umbilical cord prolapse, and fetal injury

support ± actual ROM is painless for her and fetus

may experience discomfort as the Amnihook, or other sharp instrument is inserted.
*presenting part should be engaged, and well applied to the cervix before procedure to prevent cord
prolapse
woman should be free of active infection of the genital tract, and HIV negative

*assess FHR before and immediately after to detect any changes (transient tachycardia is common.. but
brady and variable decels are not) that may indicate cord compression, or prolapse
women¶s temperature needs to be checked at least q 2 hours or per policy
more frequently if sx of infection are present
temp 38 degrees or higher, notify PCP

sx: chills, uterine tenderness on palpation, foul-smelling vaginal discharge, fetal tachycardia
Comfort measures * - frequently changing underpads, and perineal cleansing


4



-explain procedure to woman
-assess FHR before the procedure begins to obtain baseline reading
-place several underpads under women¶s buttocks to absorb fluid
-position woman on a padded bed pad, fracture pan, or rolled up towel to elevate hips
-assist who is performing procedure, with sterile gloves, and lubricant for vaginal exam
-unwrap sterile package containing Amnihook of Allis clamp, and pass instruments to the PCP, who
inserts it alongside the fingers and then hook and tears membranes
-reassess the FHR
-assess color, consistency, and odor of fluid
-assess women¶s temperature every 2 hours or per protocol
-evaluate s/sx of infection

$ 

 
-time and rupture
-color, odor, and consistency of fluid
-FHR before and after
-maternal status (how well tolerated)

'>5(')
hormone normally produced by the posterior pituitary gland that stimulates UC and aids in milk let down
Synthetic oxytocin (Pitocin) may be used to either induce labor, or augment a labor that is progressing
slowly b/c of inadequate UCs
*most commonly used« but also most commonly associated w/ A/E during childbirth
*high-alert medication²when used inappropriately

maternal hazards ± pain, abruption placentae, uterine rupture, unnecessary cesarean birth caused by non-
reassuring FHR patterns, postpartum hemorrhage, and infection
contractions too frequent, or prolonged, fetus can experience hypoxemia, academia
ü late decels, & minimal or absent baseline variability

GOAL * produce UCs of normal intensity, duration, and intensity while using the lowest dose of
medication possible

Recommendation ± starting dose of 1 milliunit/min and increasing by 1-2 milliunits no more frequently
than every 30 to 60 minutes

Uterus responds to oxytocin within 3-5 minutes of IV administration

half-life of oxytocin (time required to metabolize and eliminate one half the dose) is approximately 10-12
minutes
approximately 40 minutes is required to reach a steady state of oxytocin, point where IV administration
meets rate of elimination
low dose ± (physiologic) protocols result in less uterine hyperstimulation, decrease fetal compromise, and
significantly reduced use of oxytocin w/o affecting the duration of labor or c-section birth rate

High-dose protocols ± initial dose is larger, and dose level is increased more rapidly
have been found to result in reduced lengths of labor, and fewer forceps-assisted and c-section births
caused by dystocia.
but, have been associated w/ increased uterine hyperstimulation, increased c-section births r/t fetal stress

some give oxytocin 10 minutes ± more similar to body¶s release

OXYTOCIN
action ± hormone produced in the posterior pituitary gland that stimulates uterine contractions, and aids in
milk let down. Pitocin is a synthetic form of this hormone

used primarily for labor induction and augmentation

IV solution containing oxytocin should be mixed in a standard concentration

10 units in 1000mL of fluid
20 units in 1000mL of fluid
30 units in 500 mL of fluid

secondary line ± connected to the main line at the proximal port (closest to the IV insertion site)
always administered by pump

begin @ 1milliunit per minute

increased rate by 1-2 milliunits per minute, no more frequently than 30-60 minutes
Goal ± produce acceptable UC as evidenced by:
Consistent achievement of 200-220 motevideo units
or consistent pattern of one contraction, every 2-3 minutes, lasting 80-90 seconds, and strong to palpation

Nursing:
Explain reasons for using oxytocin to patient and family
inform the women as to the reactions to expect concerining the nature of contractions, intensity of the
contraction increasing more rapidly, holds the peak longer, and ends more quickly; will come regularly,
and more often
Everyone is different on the amount they need, some need very little, others need larger doses
Assess FHR every 15 minutes, or change in dose
Monitor UC pattern, and resting tone every 15 minutes, or change in dose
Monitor BP, R, P, every 30-60 minutes, or change in dose
Assess I&O, limit IV to 1000mL / 8 hours; output more than 120mL / 4 hours
Vaginal exam
Monitor side effects, n/v, hypotension, headache
Uterine Tachysystole ± ( know treatment)
Standard concentration of Oxytocin to minimize risk of patient harm
Rate needs to be continuously titrated to the lowest dose that achieves acceptable labor progress
(usually can be decreased, or d/c after ROM or in the active stage of 1st stage of labor)
Document time infused, each time increased, decreased, or discontinued
Document interventions for uterine tachysystole, and nonreassuring FHR and women¶s response to
interventions
Document notification of PCP and that person¶s response
!c!,!5
&
(  
42'#



more than 5 contractions in 10 minutes
series of single contractions lasting more than 2 minutes
contractions of normal duration occurring within 1 minute of eachother

)
 
 642 /%7
reposition or maintain women in side-lying position
administer IV bolus w/ 500 mL of LR
if uterine activity does not return to normal after 10 minutes ± decrease oxytocin by ½
if uterine activity does not return after this, d/c oxytocin until fewer than 5 contractions / 10 mins

)
 
 642 $ /%7

d/c oxytocin infusion immediately
reposition or maintain side lying position
administer IV bolus of 500 mL of LR
? give oxygen 10 L / min by nonrebreather if above interventions do not resolve pattern
if no response, ? give 0.25 mg Terbutaline SC
notify PCP of actions, and maternal/fetal responses



  '#
 
 
  (  

If oxytocin infusion has been d/c for less than 20-30 mins, resume at no more than ½ rate that has caused
tachysystole
if oxytocin infusion has been d/c for more than 30-40 mins, resume at the initial starting dose



    
stimulation of UC after labor has started spontaneously but progress if unsatisfactory
usually for management of hypotonic uterine dysfunction, resulting in slowing of labor

common methods ± oxytocin infusion, and amniotomy

noninvasive methods ± empty bladder, ambulation and positioning changes, relaxation, nourishment,
hydration

active management of labor ± aggressive use of oxytocin so that woman gives birth within 12 hours
intervening early, with higher than normal amounts, given at frequent intervals, shortens labor

Operative Vaginal Birth

assistance of forceps of vacuum extractor
decision is based on experience, personal preference of physician

Forceps-Assisted Birth
instrument with 2 curved blades us used to assist birth of the fetal head
cephalic-like curve similar to shape of fetal head, with pelvic curve to the blades conforming to the curve
of the pelvic axis
locks prevent the forceps from compressing fetal skull

maternal indications for forceps-assisted birth include

-prolonged 2nd stage of labor, need to shorten the 2nd stage of labor for maternal reasons
fetal indications ± fetal distress, abnormal rotations, arrest of rotation, delivery of head in breech position
*use of forceps is decreasing, replaced by vacuum, or c-section

must be fully dilated to prevent lacerations or hemorrhage

bladder should be empty
presenting part must be engaged
membranes must be ruptured

** FHR is assessed, reported, and recorded before and after application of the forceps
assess for vaginal/cervical lacerations, urinary retention, hematoma formation
infant ± bruising or abrasions at site of blade application, facial palsy from pressure on facial nerve, or
subdural hematoma
*newborn and postpartum providers should be told forceps were used

" $


attachment of vacuum cap to the fetal head, using negative pressure to assist in the birth of the head
generally not used before 34 weeks
easier, less anesthesia, easier to learn to use
risk ± cephalohematoma, scalp laceration
maternal ± perineal, vaginal, cervical lacerations, soft-tissue hematomas

documentation
pass on information to post-partum and newborn providers
observe application site
cerebral irritation (poor sucking, or listlessness)
caput succedaneum usually disappears 3-5 days

;
Assess FHR frequently during the procedure
Ecourage woman to push during contractions
Do not exceed the ³green zone´ indicated on pump, verify amount of pressure w/ physician
Document # of pulls attempted, maximal pressure used, and any pop-offs that occurred

  

birth of a fetus through a transbdominal incision
loss of experience may have negative effect on women¶s self concept
focus on birth of child, rather than operative procedure

they do it to preserve life of fetus, mother, or if complications exist

incision made in lower uterine segment ü more effective healing
c-section still poses threats

31.1% in 2006 ± highest rate reported

factors ± macrosomnia, advanced maternal age, obesity, gestational diabetes, multifetal pregnancy
elective c-section at maternal request 2.5%

*lower c-section ± support from another woman, nurse, midwife, doula


 #$..)
    


indications ± few, placenta previa, abruption?

c
 
cardiac disease (marfan¶s, unstable CAD)
respiratory disease (Guillian Barre)
conditions w/ Icreased ICP
mechanical obstruction of lower uterine segment (tumor, fibroids)
history of previous c-section

/

nonreassuring fetal status
malpresentation
active maternal herpes lesions
maternal HIV with vital load >1000 copies /mL
congenital anomalies

c
 $/

dystocia (CPD, ³failure to progress)
placental abruption
placental previa
elective c-section

/ $
 
when mother refuses to undergo c-section when indicated for fetal reasons (maternal-fetal conflict)
providers are ethically obliged to protect the well-being of mother and fetus
if woman refuses, health care providers need to find out why, provide info to help persuade her decision
? still refuses ± obtain court order?

 ( ?

skin incision, vertical ± extending from near umbilicus to the mons pubis, or transverse (pfannenstiel
incision) in the lower abdomen
transverse sometimes called bikini most commonly done

uterine incision are the low transverse and the vertical which may be low, or classic

90% is low transverse uterine incision


vertical ± underdeveloped lower uterine segment, transverse lie, preterm breech presentation, certain fetal
anomalies (massive hydrocephalus, anterior placenta previa)

*higher incidence of uterine rupture in vaginal births after classic uterine incision

 

 0
aspiration, hemorrhage, atelectasis, endometritis, abdominal wound, dehiscence or infection, UTI, injuries
to bowel or bladder, complications r/t anesthesia

fetus ± born pretmaturely if gestational age not determined

fetal asphyxia can occur if placenta or uterus is poorly perfused b/c of maternal hypotension caused by
regional anesthesia (epidural or spinal) or maternal positioning
fetal injuries (scalpel lacerations) can also occur during surgery

c-section more expensive, longer recovery


 
spinal, epidural, general
*epidural blocks ± b/c women are awake, and aware of birth experience
fully informed of risks and benefits

 $
 
if vaginal birth is contraindicated
complete placenta previa, active gential herpes, HIV positive w/ high viral load

have time to prepare

relieved

&
 $
 
psychosocial more pronounced and negative than compared w/ scheduled/planned
abrupt changes occur; experience is traumatic for all involved
tired, discouraged after ineffective/difficult labor
fear own safety, as well as fetus¶
dehydrated, low glucogen reserves
pre-op : little time is available ± may feel unprepared, uninformed
anxiety high ± may forget what people said
anger, guilt, fatigue in postpartum




 
no woman can be guaranteed a vaginal birth
women need to be prepared of possibility of c-section
continuing presence and support of partner helped them respond positively to their experience



  ;
family centered
same as any other elective or emergency procedure
discussed need for c-section, and prognosis
anesthesiology will assess cardiopulmonary system
informed consent
blood tests, CBC, blood type, Rh status
maternal VS and FHR assessment per hospital policy
IV fluids ± hydration
catheter
Abx
check consents
shave / clip pubic hair if needed
TED hose / SCD boots to prevent blood clots
remove jewelry (depending) polish, dentures, nail polish
*make sure bring glasses in OR so she can see infant

support person, be present as possible

continuing emotional support, if not, nurse give information frequently
nurse ± verbal communication during, explain as much as possible (may be very anxious)
*nurse teaching, expectations, TCDB, pain relief

uterus displaced laterally & wedge placed under hip during procedure to prevent decreased
placental perfusion
women¶s legs may be strapped to ensure proper positioning

nurse from L&D present for care of baby

pediatrician or nurse skilled in neonate resuscitation
infants condition ok ± skin to skin contact - -mother or partner
compromised ü stabilized then taken to nursery for observation, interventions as appropriate
partner may go with infant
if not, progress given as soon as possible
other family members in waiting room ± doctor reports on conditions, and that birth is completed
*ask family what you can tell them ± some people keep gender, then will tell family themselves

 


  
mother transferred to PACU
postpartum & postop needs that must be met! (surgical patients, also new mothers)
airway*
VS q 15 mins for 1-2 hours until stable
positioning
incisional dressing, fundus, lochia assessed
IV intake, and UO from foley
TCDB, leg exercises

bonding
breastfeeding
transferred when stable, and when anesthesia wears off (she is alert, able to feel and move
extremities)
medication given promptly, before pain is severe

*Postpartum/Postop care
mother 1st, post-op patient 2nd
physiologic concerns may be dominated by pain at incision site, and intestinal gas
first 24 hours pain relief by epidural opiods, pca, IV or IM injections ü oral
position changes, splinting of incision w/ pillows, breathing, relaxation

fluid/ foods ± usually NPO, or ³sips and chips´

diet advanced to full liquids ü pass gas ü then regular
ambulation or rocking chair can help w/ gas pains

daily care ± perineal care, breast care, routine hygiene

shower 1st post op day, after dressing is off
foley removed 1st post op day *ambulation encouraged several times / day
per policy ± assess fundus, lochia, VS, incision
breath sounds, bowel sounds, CSM of lower extremities, elimination assessed
maternal emotional status also

can give emotional support, teaching as needed

help plan care at home, and family visits to allow for rest & adjustment as mother
breastfeeding support and encouragement; give individual assistance
football hold support newborn, use pillows for comfort and successful breastfeeding
include partner*
allow for expression of feelings
some are angry, frustrated, or disappointed that vaginal birth was not possible
low-self esteem, negative body image,
-- others; relief and gratitude baby was born and healthy
usually 3rd post-op day discharge home
*Newborn & Mother¶s Health Protection Act of 1996 ± LOS up to 96 hours for c-section
may be able to leave earlier, or stay later depending
home care visits if needed

  

 

 
*temperature greater than 38 (100.4)
*painful urination
*lochia heavier than a normal period
*wound separation
*redness or oozing at incision site
*severe abdominal pain

('(    
observance of woman for reasonable time period (4-6 hours) of spontaneous active labor to
assess the safety of vaginal birth for mother and fetus
most common -- * mother wants VBAC
women is evaluated for occurrence of active labor, contractions, engagement and descent of
presenting part, effacement and dilation
assesses VS and FHR, contractions, alert for signs of complications
appropriate actions ü responses to interventions, notifying PCP, evaluation / documentation
support and encouragement, provide information

""  
 
  

success rate is 70-80%
Benefits -- shorter maternal hospital stay, less blood loss, fewer infections, fewer
thromboembolic events
Risks -- uterine rupture, hysterectomy, operative injury, neonatal morbidity

spontaneous labor more likely to result in a successful labor than has been induced or augmented
<35 years old, fetus weight less than 4000g, previous C- section was performed for some other
reason than failure to descent in 2nd stage of labor

after being informed of risks/benefits ± about 25% of potential candidates choose repeat c-
section
*emotional support needed during TOL b/c increased anxiety can lead to release of
catecholamines, inhibiting release of oxytocin ü delay in labor. therefore another c-section


 
  "

-one previous low transverse c-section
-clinically adequate pelvis
-no other uterine scars, or history of previous rupture
-Physician immediately available throughout active labor, and capable of monitoring labor and
performing emergency c-section if necessary
-availability of anesthesia and personnel for emergency c-section

 

 -   


Post-term (postdate, or prolonged pregnancy)

one that extends beyond the end of 42nd week gestation
4%-14%
cause uknown
more common in 1st time mother
likely that next pregnancies will also be post-term

c
 2/


perineal injury r/t macrosomnia
use of interventions (forceps, oxytocin, vacuum, prostaglandins) ± each have own risks
fatigue, physical discomfort, inadequacy, frustration
macrosomnia occurs far more often ± placenta continues to provide adequate nutrients and
supports fetal growth after 40 weeks
increased risk for birth injury

other risks r/t intrauterine environment

placenta ages after 43-44 weeks (infarction, increased deposits of calcium and fibrin, decreased
reserve) all affected ability to oxygenate fetus
decreased amniotic fluid <400 mL * complications most associated w/ post-term
ü increases likelyhood of cord compression
meconium-stained amniotic fluid ü increased aspiration, low APGAR score
oligohydramnios magnifies effect of meconium-stained amniotic fluid
less fluid makes meconium more thicker, stickier than it would be otherwise

dysmaturity syndrome * occurs in 20% of post-term pregnancies

dry, cracked, peeling skin, long nails, meconium stains of skin, nails, umbilical cord,
loss of SC fat and muscle mass
usually regain weight quickly, and exhibit few longterm neuro problems
 
$
 
-perform daily fetal movement counts
-assess for signs of labor
-call PCP if membranes rupture or if you perceive decrease in fetal movements
-keep appointments
-come to hospital as soon after labor begins

physicians usually induce at 41 weeks

encourage to express feelings
during labor ± continually assessed
inadequate fluid volume can lead to compression of cord ü fetal hypoxia (variable or prolonged
decelerations)
oligohydramnios ü amnioinfusion may be performed to restore volume

c 

/

indicates that the fetus has passed meconium (1st stool)
green in color, thick or thin

3 reasons for passage of meconium

1) normal, occurs with maturity
infrequent before 23-24 weeks.
increased incidence after 38 weeks
breech presentation

2) result of hypoxia-induced peristalsis and sphincter relaxation

3) sequel to umbilical cord compression ± induced vagal stimulation in mature fetuses

major risk ± ASPIRATION

MAS ± Meconium Aspiration syndrome
can cause severe form of pneumonia that most often occurs in term, or post-term infants
most likely results from long-standing intrauterine process, rather than immediately after birth

*presence of team trained in resuscitation is needed

NO longer routine suction of mouth and nose, or endotracheal suctioning

ü based on infant¶s condition at birth


)
c  
 4 4
c 

/
 

-assess amniotic fluid for presence of meconium after ROM
-if it is stained, gather equipment necessary for neonatal resuscitation before birth
-have someone capable of performing resuscitation ± and endotracheal intubation

)


-assess baby¶s respiratory efforts, HR, muscle tone
-suction baby¶s mouth and nose if the baby has:
strong resp. efforts, good muscle tone, HR > 100 bpm
-suction below vocal cords using endotraceal tube to remove any meconium present before many
spontaneous respirations have occurred, or assisted ventilation has been initiated if the baby has:
-depreseed resp, decreased muscle tone, HR <100 bpm

 
 
uncommon obstetric emergency that increases the risk for fetal / maternal morbidity and morality
during the attempt to deliver the fetus vaginally

condition where the head is born, but the shoulder cannot pass under the pubic arch
fetopelvic disproportion r/t excessive fetal size or maternal pelvic abnormalities may cause the
shoulder dystocia, although up to half of all cases occur w/ fetuses of smaller size
other risk factors ± maternal diabetes, history in previous birth, prolonged 2nd stage of labor
in half of all cases ± no risk factors

*** early warning sign

during 2nd stage of labor, retraction of head against the perineum immediately after immergence
(turtle sign)

fetal injuries caused by asphyxia

trauma r/t maneuvers

complications r/t trauma brachial plexus and phrenic nerve injuries, fx of humerus or clavicle
*most serious brachial plexus injury (erb palsy) which occurs in 10-20%
if recognized early, and treated properly 80-90% resolve

postpartum hemorrhage and rectal injuries

Management ±
suprapubic pressure can be applied, maternal position changes to free anterior shoulder
McRobert¶s maneuver woman¶s knees flexed apart, knees on her abdomen.
causes sacrum to straighten, symphysis pubis rotates toward mother¶s head
suprapubic pressure can be applied also
*preferred when given epidural anesthesia

hands-knees position (Gaskin) if mother has motor function

squatting
lateral recumbent position

nurse needs to stay calm, call for additional assistance immediately

anesthesia team, neonatal resuscitation team
reduce anxiety and fear ± provide support
assessment ± include for fx of clavicle or humerus, as well as brachial plexus and asphyxia
maternal ± hemorrhage, trauma to vagina, perineum, rectum

Prolapsed Umbilical Cord

occurs when the cord lies below the presenting part of the fetus
occult during labor, whether or not membranes have ruptured or not
most commonly ± frank (visible) directly after ROM

factors ± long cord (> 100 cm), malpresentation (breech), or unengaged presenting part
if the presenting part does not fit snugly in the lower uterine segment (hydramnios), the gush of
fluids may cause cord to be displaced downward
or during amniotomy
or small fetus who does not fit snugly

*prompt recognition b/c fetal hypoxia can result from prolonged cord compression
(occlusion of blood flow to and from fetus for more than 5 minutes) usually results in CNS
damage, or death of fetus

pressure may be relieved by examiner putting sterile gloved fingers in to keep fetus off cord

positions ± modified sims (hips high on pillow)

knee-chest

c-section is likely to be performed

nonreassuring FHR, inadequate uterine relaxation, bleeding can result

 
 


-variable or prolonged decelerations during UCs
-women reports feeling cord after ROM
-cord is seen or felt in or protruding from vagina

)
 
 
-call for assistance
-notify PCP immediately
-sterile gloves quickly, insert, exert pressure on presenting part to relieve pressure
-do not move your hand! have another person reposition
-extreme Trendelenburg, or modified Sims
-if cord is protruding, wrap loosely in a sterile towel saturated w/ warm sterile NS
-admnister 8-10L nonrebreather facemask
-start IV or increase drip rate
-continue to monitor FHR continuously (fetal scalp electrode if possible)
-explain what is happening, support
-prepare for immediate vaginal if cervix is fully dilated ± c-section if not
Rupture of the Uterus
rare, but very serious injury occurs 1 in 2,000 births
major risk factor is a TOL for attempted VBAC
depends on both type, and location of uterine scars
occurs most often with classic incision (vertical lower segment)
other risk factors ± labor induction, multiple prior c-sections, other uterine surgeries, multiparity,
trauma

uterine dehiscence ± incomplete uterine rupture is a separation of a prior scar

may go unnoticed unless woman has c-section, or other uterine surgery
complications low b/c does not result in hemorrhage

s/sx vary
most common ± reassuring FHR, variable & late decelerations, bradycardia, absent/minimal
variable
loss of fetal station may occur
constant abdominal pain, uterine tenderness, change in uterine shape, cessation of contractions
sx of hypovolemia r/t hemorrhage (hypotension, tachycardia, pallor, cool, clammy skin)
placenta seperates ± FHR will be absent
fetal parts may be palpable through abdomen

*prevention is best treatment

previous c-sections not advised to do VBAC
labor induced w/ oxytocin ± monitored for uterine tachysystole b/c contractions that occur too
frequently or too long can precipitate uterine rupture
if tachysystole occurs ± oxytocin d/c or slowed, a tocolytic agent may be given to decrease
intensity
after birth ± assessment of sx of bleeding *fundus.
rupture occurs ± laparotomy, birth of infant, repair of laceration, blood transfusions as needed
hysterectomy if rupture is large, and difficult to close or if the woman is hemodynamically
unstable
*starting IV fluids, blood, oxygen, preparation
support family
fetal morality high 50-75%
maternal can be high if not treated immediately


 
   
aka: amniotic fluid embolism

rare, but devastating complication of pregnancy

sudden, acute hypoxia, hypotension, cardiac arrest, coagulopathy
ASP occurs during labor, during birth, or within 30 mins after birth
*similar to patients with anaphylactic or septic shock
foreign substance introduced into circulatory system, resulting in disseminated intravascular
coagulation, hypotension, hypoxia
foreign substance present in amniotic fluid, introduced into maternal circulation
exact factor that initiates ASP is unknown
particles of fetal debris found, but can occur normally (vernix, hair, skin cells, meconium)
mortality rate is 61% or higher
surviving neonates usually have neurological impairments

maternal factors ± multiparity, tumultuous labor, placental abruption, oxytocin, fetal problems ±
macrosomnia, death, meconium passage ± increased risk of development

Immediate interventions ±
CPR
perimortem c-section within 5 minutes
transfer to ICU
replace blood, clotting factors, hydrate, ventilator


!$
;
Respiratory Distress:
restlessness, dyspnea, cyanosis, pulmonary edema, respiratory arrest
Circulatory Collapse:
hypotension, tachycardia, shock, cardiac arrest
Hemorrhage:
coagulation failure ± bleeding from incisions, venipuncture sites, trauma, petechiae, ecchymoses,
purpura, uterine atony

)
 
 

-give o2 8-10 L / min face mask nonrebreather ± or resuscitation bag 100% oxygen
-prepare for intubation and mechanical ventilation
-initiate or assiste CPR
-tilt woman 30 degrees to side to displace uterus
maintain CO and replace fluid losses
- position woman on her side
administer IV fluids
administer blood, packed cells, ffp
insert catheter, measure hourly output

correct coag failure

monitor fetal / maternal status
prepare for emergency birth
provide emotional support