High-Risk Labor and Preterm Birth

High-Risk Labor and Birth

• Perinatal morbidity and mortality risks increase when complications arise during labor and birth
• Complications may be anticipated, especially in mothers identified as high-risk, and others may be unexpected
• Nurses must be able to Understand the normal birth process, Prevent deviations from normal labor, Detect deviations from normal labor, Implement nursing measures

Preterm Labor and Birth

• Regular uterine contractions alongside cervical effacement and dilation occurring between 20 and 37 weeks of gestation
• One of the most common obstetric complications and leads to preterm birth if contractions are not stopped

Risk Factors for Preterm Labor

• Infections
• Previous preterm labor
• Black race
• Placenta previa or Abruptio placentae
• Multiple gestation
• Pre-pregnancy underweight or obesity (BMI > 30)
• Smoking
• Substance abuse
• Low socioeconomic status
• High levels of personal stress

Assessment for Predicting Preterm Labor

• Change in vaginal discharge
• Pelvic pressure
• Low back ache
• Cervical length
• Presence of fetal fibronectin (fFN)
• More than six contractions in an hour
• Four contractions every 20 minutes, or eight contractions in 1 hour

Nursing Assessment for Preterm Labor

• Risk factors
• Preterm labor contractions
• Lab and Diagnostic testing like CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length measurement via transvaginal ultrasound, and cervical culture

Interventions for Preterm Labor

• Early recognition and diagnosis
• Lifestyle modifications of activity and restriction of sexual activity

Suppression of Uterine Activity

• Tocolytic therapy used to stop uterine contractions and usually only delays delivery
• Magnesium Sulfate is given to relax smooth muscle of the uterus
• Brethine (Terbutaline) is a Beta-adrenergic
• Nifedipine (Procardia) is a calcium channel blocker
• Indomethacin (Indocin) inhibits Prostaglandin

Promotion of Fetal Lung Maturity

• A Corticosteroid, Betamethasone is administered

Nursing Interventions for Uterine Suppression

• Assessment of mother and fetus is a priority with immediate care
• Have Calcium Gluconate available if administering Magnesium Sulfate
• Discharge teaching includes warning signs of preterm labor
• Antibiotic prophylaxis administered for women with group B streptococcus

Prelabor Rupture of Membranes (PROM)

• Rupture of the amniotic sac and leakage of amniotic fluid at least 1 hour before the onset of labor at any gestational age
• Risk factors include a history of preterm PROM, short cervical length, low socioeconomic status, and smoking or illicit drug use
• Infection is a major risk factor

PROM Care Assessment and Interventions

• Determine risk estimate for each woman
• Monitor fetal heart rate
• Monitor maternal vital signs, especially temperature, frequently

Greatest Risk in PROM Cases

• Infection, assessed via labs (CBC)
• Labor may be induced, and hospitalization is usually required

Chorioamnionitis

• Bacterial infection of the amniotic cavity involving inflammation of the fetal amnion and chorion membranes
• Bacteria ascends into uterus from vagina

Risk Factors for Chorioamnionitis

• Prolonged rupture of membranes
• Multiple vaginal exams
• Use of internal fetal monitoring

Signs and Symptoms of Chorioamnionitis

• Maternal fever greater than 100.4°F
• Maternal and fetal tachycardia
• Uterine tenderness
• Foul-smelling amniotic fluid

Treatment for Chorioamnionitis

• IV broad-spectrum antibiotics, such as PCN or ampicillin
• Placenta sent to pathology
• Neonate followed up with blood cultures and IV antibiotics until blood culture results are negative

Nursing Actions for Chorioamnionitis

• Communicate findings
• Assess maternal WBC count for levels greater than 15,000
• Administer antibiotics and antipyretics as ordered

Post-Term Pregnancy

• Pregnancy that has completed 42 weeks of gestation
• The etiology is unknown but always review EDD to confirm dates

Maternal Risks in Post-Term Pregnancy

• Large fetus
• Increased risk for Cesarean birth
• Dystocia
• Birth trauma
• Postpartum hemorrhage
• Infection
• Increased likelihood of needing forceps or vacuum-assisted birth and/or induction of labor

Fetal Risks in Post-Term Pregnancy

• Macrosomia
• Shoulder dystocia
• Brachial plexus injuries
• Low Apgar scores
• Decreased perfusion
• Meconium staining
• Cephalopelvic disproportion

Placenta Aging

• Placental perfusion decreases as the placenta ages

Nursing Assessment and Management of Post-Term Pregnancy

• Estimated date of birth
• Daily fetal movement counts
• Nonstress tests twice weekly
• Biophysical profile and Amniotic Fluid Index (AFI)
• Weekly cervical exams
• Assess client understanding of the plan
• If determined plan to wait, then fetal surveillance in key

Dystocia

• Difficult labor
• Defined as "failure to progress"
• Term used to describe an abnormally long labor, may result in a cesarean section

Factors Influencing Labor (5 P’s) Which Focus on Abnormalities

• Powers: Ineffective uterine contractions and maternal pushing
• Passage: Alterations in the pelvic structure
• Passenger: Fetal causes; fetal presentation
• Position: Maternal positioning during labor
• Psychologic: Response of the woman

Hypertonic Uterine Dysfunction

• Uterus does not fully relax between contractions
• Risk factors include induction or augmentation of labor, tachysystole, and abruption
• Assess for frequent contractions, inadequate resting tone, and little cervical change, may have Category II or III FHR pattern
• Evaluate, hydrate, may need medication, assess FHR and contractions, promote relaxation

Hypotonic Uterine Dysfunction

• Occurs during active labor
• Uterine contraction is insufficient (<25 mm Hg) to promote cervical dilation and effacement
• Risk factors include an overstretched uterus, bladder distention
• Assessment findings include decreased frequency, duration, and intensity of contractions, with little to no cervical change
• Evaluate labor progress, assess uterine activity and fetal status, and consider augmentation with oxytocin