Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Chapter 32 Labor and Birth Complications Copyright © 2016 by Elsevier Inc. All rights reserved. Learning Objectives Differentiate between preterm birth and low birth weight. Describe the criteria for very preterm, early preterm, late preterm, and the implications of each. Discuss major risk factors associated with preterm labor. Analyze current interventions to prevent spontaneous preterm birth. Copyright © 2016 by Elsevier Inc. All rights reserved. 2 Learning Objectives (Cont.) Discuss the use of tocolytics and antenatal glucocorticoids for management of preterm labor. Design a nursing care plan for women with preterm premature rupture of membranes (preterm PROM). Explain the care of a woman with postterm pregnancy. Explain the challenge of caring for obese women during labor and birth. Copyright © 2016 by Elsevier Inc. All rights reserved. 3 Learning Objectives (Cont.) Summarize the nursing care for a trial of labor, the induction and augmentation of labor, forceps- and vacuum-assisted birth, cesarean birth, and vaginal birth after a cesarean birth (VBAC). Discuss obstetric emergencies and their appropriate management. Copyright © 2016 by Elsevier Inc. All rights reserved. 4 Preterm Labor and Birth Preterm labor and birth Preterm labor (PTL): cervical changes and uterine contractions occurring at 20 to 37 weeks of pregnancy Preterm birth: birth that occurs before the completion of 37 weeks (<37 0/7 weeks of gestation) Copyright © 2016 by Elsevier Inc. All rights reserved. 5 Preterm Labor and Birth (Cont.) Preterm birth versus low birth weight Preterm birth or prematurity: length of gestation regardless of birth weight • More dangerous than birth weight alone because less time in the uterus correlates with immaturity of body systems Low birth weight: ≤2500 grams at birth • Many potential causes, including preterm • Intrauterine growth restriction (IUGR) Copyright © 2016 by Elsevier Inc. All rights reserved. 6 Preterm Labor and Birth (Cont.) Spontaneous versus indicated preterm birth Spontaneous: 75% of preterm births Indicated: 25% of preterm births Causes of spontaneous preterm labor and birth Multifactorial Infection is the only definitive factor Placental causes Copyright © 2016 by Elsevier Inc. All rights reserved. 7 Preterm Labor and Birth (Cont.) Predicting spontaneous preterm labor and birth Risk factors Cervical length • Not predictive of PTL or birth • But cervical length >30 mm unlikely to give birth prematurely Fetal Fibronectin (fFN)Test • fFN is a glycoprotein “glue” found in plasma and produced during fetal life. Copyright © 2016 by Elsevier Inc. All rights reserved. 8 PTL Care Management Assessment Interventions Patient teaching Prevention Early recognition and diagnosis Lifestyle modifications Activity restriction Restriction of sexual activity Home care Copyright © 2016 by Elsevier Inc. All rights reserved. 9 PTL Care Management (Cont.) Suppression of uterine activity Promotion of fetal lung maturity Tocolytic medications Antenatal glucocorticoids: significantly reduce the incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death in neonates Management of inevitable preterm birth Fetal and early neonatal loss Copyright © 2016 by Elsevier Inc. All rights reserved. 10 Premature Rupture of Membranes (PROM) PROM: Spontaneous rupture of amniotic sac and leakage of fluid prior to the onset of labor at any gestational age PPROM: membranes rupture before 37 0/7 weeks of gestation Responsible for 10% of all preterm births Often preceded by infection • Chorioamnionitis Copyright © 2016 by Elsevier Inc. All rights reserved. 11 PROM and PPROM Care Management Determined individually for each woman Full-term birth is the best option. PPROM <32 weeks is managed expectantly and conservatively. Vigilance for signs of infections Fetal assessment Antenatal glucocorticoids Copyright © 2016 by Elsevier Inc. All rights reserved. 12 Chorioamnionitis Bacterial infection of the amniotic cavity Major cause of complications for mothers and newborns at any gestational age Diagnosed by the clinical findings of maternal fever, maternal and fetal tachycardia, uterine tenderness, and foul odor of amniotic fluid Neonatal risks Treatment Copyright © 2016 by Elsevier Inc. All rights reserved. 13 Postterm Pregnancy, Labor, and Birth Postterm pregnancy (postdates) pregnancy ≥42 weeks of gestation Maternal risks Dysfunctional labor and birth canal trauma Labor and birth interventions more likely Woman may experience fatigue and psychologic reactions as estimated date of birth passes. Copyright © 2016 by Elsevier Inc. All rights reserved. 14 Postterm Pregnancy, Labor, and Birth (Cont.) Fetal risks Abnormal fetal growth (macrosomia) Prolonged labor Shoulder dystocia Birth trauma Compromising effects on fetus of “aging” placenta Postmaturity syndrome Copyright © 2016 by Elsevier Inc. All rights reserved. 15 Postterm Pregnancy, Labor, and Birth (Cont.) Care management Controversial Perinatal morbidity and mortality increase greatly after 42 weeks of gestation. More frequent fetal assessment, testing Copyright © 2016 by Elsevier Inc. All rights reserved. 16 Case Study Your client is a G2 P1001 at 42 weeks gestation. Her biophysical profile (BPP) exam was 4/10. • What does this mean about the health of her fetus? • Given her gestational age, what are some of the potential causes of this condition? Copyright © 2016 by Elsevier Inc. All rights reserved. 17 Case Study (Cont.) Her cervical exam reveals cervix is closed/long/ -3/firm/posterior • What is her Bishop’s score? • Given this score, what type of induction orders might the nurse anticipate? Copyright © 2016 by Elsevier Inc. All rights reserved. 18 Case Study (Cont.) What potential newborn complications might the nurse expect at birth? Describe some typical features of the postdates newborn. Copyright © 2016 by Elsevier Inc. All rights reserved. 19 Dysfunctional Labor (Dystocia): Overview Long, difficult, or abnormal labor Most common indication for c-birth Five factors affect labor • The powers • The passage • The passenger • Maternal position • Psychologic responses Copyright © 2016 by Elsevier Inc. All rights reserved. 20 Dysfunctional Labor (Dystocia): Causes Abnormal uterine activity Hypertonic uterine dysfunction • Therapeutic rest Hypotonic uterine dysfunction • Initially makes normal progress into the active phase of first-stage labor but then the contractions become weak and inefficient or stop altogether Copyright © 2016 by Elsevier Inc. All rights reserved. 21 Dysfunctional Labor (Dystocia): Causes (Cont.) Secondary powers Abnormal labor patterns Problems with bearing-down efforts Friedman’s classification of “normal” labor patterns Updated, evidence-based awareness of “normal” labor Precipitous labor Labor that lasts less than 3 hours from the onset of contractions to the time of birth Copyright © 2016 by Elsevier Inc. All rights reserved. 22 Dysfunctional Labor (Dystocia): Causes (Cont.) Alterations in pelvic structure Pelvic dystocia • Contractures of pelvic diameters that reduce the capacity of the bony pelvis, inlet, midpelvis, or outlet Soft-tissue dystocia • Results from obstruction of the birth passage by an anatomic abnormality other than that of bony pelvis Copyright © 2016 by Elsevier Inc. All rights reserved. 23 Dysfunctional Labor (Dystocia): Causes (Cont.) Fetal causes Anomalies Cephalopelvic disproportion (CPD), also called fetopelvic disproportion (FPD) Malposition Malpresentation Multifetal pregnancy Copyright © 2016 by Elsevier Inc. All rights reserved. 24 Dysfunctional Labor (Dystocia): Causes (Cont.) Position of the woman Maternal position alters relationship between uterine contractions, fetus, and mother’s pelvis Psychologic responses Hormones and neurotransmitters released in response to stress can cause dystocia Sources of stress and anxiety vary Copyright © 2016 by Elsevier Inc. All rights reserved. 25 Obesity Serious problem in affluent nations BMI of 30 kg/m2 or greater BMI of 40 kg/m2 or greater extremely obese Complications Venous thromboembolism Cesarean birth Copyright © 2016 by Elsevier Inc. All rights reserved. 26 Obstetric Procedures: Version External cephalic version (ECV) An attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth Ultrasound scanning used during procedure NST and informed consent before procedure Contraindications to ECV Internal version Rarely used; safety questionable Used most often in twin gestations to deliver the second fetus Copyright © 2016 by Elsevier Inc. All rights reserved. 27 Obstetric Procedures: Version (Cont.) Copyright © 2016 by Elsevier Inc. All rights reserved. 28 Obstetric Procedures: Induction of Labor The chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about birth Labor may be induced either electively or for indicated reasons. Copyright © 2016 by Elsevier Inc. All rights reserved. 29 Obstetric Procedures: Induction of Labor (Cont.) Elective induction of labor Labor is initiated without a medical indication. Many are for the convenience of the woman or her primary health care provider. Risks: • Increased rates of cesarean birth • Increased neonatal morbidity • Increased cost Elective induction of labor should not be initiated until the woman reaches 39 completed weeks of gestation. Copyright © 2016 by Elsevier Inc. All rights reserved. 30 Obstetric Procedures: Induction of Labor (Cont.) Bishop’s score A rating system used to evaluate inducibility or cervical ripeness Copyright © 2016 by Elsevier Inc. All rights reserved. 31 Obstetric Procedures: Induction of Labor (Cont.) Cervical ripening methods Chemical agents Mechanical and physical methods Alternative methods Amniotomy Oxytocin Hormone normally produced by the posterior pituitary gland, which stimulates uterine contractions and aids in milk letdown Synthetic oxytocin (Pitocin) may be used either to induce labor or to augment labor that is progressing slowly because of inadequate uterine contractions. Copyright © 2016 by Elsevier Inc. All rights reserved. 32 Obstetric Procedures: Augmentation of Labor Stimulation of uterine contractions after labor has started spontaneously and progress is unsatisfactory Common augmentation methods include oxytocin infusion and amniotomy. Active management Copyright © 2016 by Elsevier Inc. All rights reserved. 33 Obstetric Procedures: Operative Vaginal Birth Operative vaginal births are performed using either forceps or a vacuum extractor Forceps-assisted birth Copyright © 2016 by Elsevier Inc. All rights reserved. 34 Obstetric Procedures: Operative Vaginal Birth (Cont.) Operative vaginal births are performed using either forceps or a vacuum extractor Vacuum-assisted birth Copyright © 2016 by Elsevier Inc. All rights reserved. 35 Obstetric Procedures: Cesarean Birth Overview Birth of a fetus through a transabdominal incision of the uterus to preserve the wellbeing of the mother and her fetus Cesarean birth rate in the United States has been over 32% since the early 2000s VBAC = Vaginal birth after cesarean TOLAC = Trial of labor after cesarean Copyright © 2016 by Elsevier Inc. All rights reserved. 36 Obstetric Procedures: Cesarean Birth (Cont.) Elective cesarean birth Scheduled cesarean birth Unplanned cesarean birth Forced cesarean birth Copyright © 2016 by Elsevier Inc. All rights reserved. 37 Obstetric Procedures: Cesarean Birth (Cont.) Surgical techniques Copyright © 2016 by Elsevier Inc. All rights reserved. 38 Obstetric Procedures: Cesarean Birth (Cont.) Complications and risks Anesthesia Prenatal preparation Preoperative care Copyright © 2016 by Elsevier Inc. All rights reserved. 39 Obstetric Procedures: Cesarean Birth (Cont.) Intraoperative care Copyright © 2016 by Elsevier Inc. All rights reserved. 40 Obstetric Procedures: Cesarean Birth (Cont.) Immediate postoperative care Postoperative postpartum care Nursing interventions Trial of labor Vaginal birth after cesarean Copyright © 2016 by Elsevier Inc. All rights reserved. 41 Obstetric Emergencies Meconium-stained amniotic fluid Indicates fetus has passed stool prior to birth Dark green Possible causes • Normal physiologic function of maturity • Breech presentation • Hypoxia-induced peristalsis • Umbilical cord compression Copyright © 2016 by Elsevier Inc. All rights reserved. 42 Obstetric Emergencies (Cont.) Shoulder dystocia Head is born, but anterior shoulder cannot pass under pubic arch Newborn more likely to experience birth injuries related to asphyxia, brachial plexus damage, and fracture Mother’s primary risk stems from excessive blood loss from uterine atony or rupture, lacerations, extension of episiotomy, or endometritis. Copyright © 2016 by Elsevier Inc. All rights reserved. 43 Obstetric Emergencies (Cont.) Copyright © 2016 by Elsevier Inc. All rights reserved. 44 Obstetric Emergencies (Cont.) Prolapsed umbilical cord Occurs when cord lies below the presenting part of the fetus Contributing factors include: • Long cord (longer than 100 cm) • Malpresentation (breech) • Transverse lie • Unengaged presenting part Copyright © 2016 by Elsevier Inc. All rights reserved. 45 Obstetric Emergencies (Cont.) Copyright © 2016 by Elsevier Inc. All rights reserved. 46 Obstetric Emergencies (Cont.) Rupture of the uterus Rare, serious obstetric injury; occurs in 1 in 2000 births Most frequent causes of uterine rupture during: • Separation of scar of a previous classic cesarean birth • Uterine trauma (e.g., accidents, surgery) • Congenital uterine anomaly Copyright © 2016 by Elsevier Inc. All rights reserved. 47 Obstetric Emergencies (Cont.) Rupture of the uterus (Cont.) During labor and birth • Intense spontaneous uterine contractions • Labor stimulation (e.g., oxytocin, prostaglandin) • Overdistended uterus (e.g., multifetal gestation) • Malpresentation, external or internal version • Difficult forceps-assisted birth • Occurs more in multigravidas than primigravidas Copyright © 2016 by Elsevier Inc. All rights reserved. 48 Obstetric Emergencies (Cont.) Amniotic fluid embolus (AFE), also called anaphylactoid syndrome of pregnancy (ASP) Amniotic fluid containing particles of debris (e.g., vernix, hair, skin cells, or meconium) enters the maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse Copyright © 2016 by Elsevier Inc. All rights reserved. 49 Key Points Preterm birth is any birth that occurs between 20 0/7 and 36 6/7 weeks of gestation. Preterm labor is generally diagnosed clinically as regular contractions along with a change in cervical effacement or dilation or both or presentation with regular uterine contractions and cervical dilation of at least 2 cm. The incidence of preterm birth varies considerably by race. In the United States, nonHispanic black women have the highest rate of preterm birth. The cause of preterm labor is unknown and is assumed to be multifactorial; therefore, it is not possible to predict with certainty which women will experience preterm labor and birth. Copyright © 2016 by Elsevier Inc. All rights reserved. 50 Key Points (Cont.) Because the onset of preterm labor is often insidious and can be mistaken for normal discomforts of pregnancy, nurses should teach all pregnant women how to detect the early symptoms of preterm labor and to call their primary health care provider when symptoms occur. The best reason to use tocolytic therapy is to achieve sufficient time to administer glucocorticoids in an effort to accelerate fetal lung maturity. Additionally, time is allowed for transport of the woman prior to birth to a center equipped to care for preterm infants. Copyright © 2016 by Elsevier Inc. All rights reserved. 51 Key Points (Cont.) If fetal or early neonatal death is expected, the parents and members of the health care team need to discuss the situation before the birth and decide on a management plan that is acceptable to everyone. Vigilance for signs of infection is an essential component of the care management for women with preterm PROM. Dysfunctional labor results from differences in the normal relationships among any of the five factors affecting labor and is characterized by differences in the pattern of progress in labor. Copyright © 2016 by Elsevier Inc. All rights reserved. 52 Key Points (Cont.) Obese women are at risk for several pregnancy complications, including cesarean birth. Even routine procedures require more time and effort to accomplish when the client is obese. Uterine contractility is increased by the effects of oxytocin and prostaglandin and is decreased by tocolytic agents. Labor should not be induced electively until the woman has reached at least 39 weeks of gestation. Cervical ripening using chemical or mechanical measures can increase the success of labor induction. Copyright © 2016 by Elsevier Inc. All rights reserved. 53 Key Points (Cont.) Expectant parents benefit from learning about operative obstetrics (e.g., forceps-assisted, vacuumassisted, or cesarean birth) during the prenatal period. The basic purpose of cesarean birth is to preserve the well-being of the mother and her fetus. Unless contraindicated, vaginal birth is possible after a previous cesarean birth. Copyright © 2016 by Elsevier Inc. All rights reserved. 54 Key Points (Cont.) Labor management that emphasizes one-to-one support of the laboring woman by another woman (e.g., doula, nurse, nurse-midwife) can reduce the rate of cesarean birth and increase the VBAC rate. Obstetric emergencies (e.g., meconium-stained amniotic fluid, shoulder dystocia, prolapsed cord, rupture of the uterus, and amniotic fluid embolism) occur rarely but require immediate intervention to preserve the health or life of the mother and fetus or newborn. Copyright © 2016 by Elsevier Inc. All rights reserved. 55 Question A pregnant woman arrives on the labor and delivery unit and informs the nurse that her infant is in a breech presentation. This presentation is associated with an increased risk for childhood handicap; therefore this baby will likely be delivered by cesarean birth. The client may wish to undergo an external cephalic version (ECV) in an attempt to manually reposition the baby into a vertex presentation. A number of interventions may be implemented to support this procedure and increase the likelihood of success. Studies have shown which intervention to be the most successful? a. b. c. d. Tocolysis Nitrous oxide Spinal or epidural analgesia Amnioinfusion Copyright © 2016 by Elsevier Inc. All rights reserved. 56