Labor and Birth: Dystocia

• Labor and birth can present various complications that require prompt recognition and intervention by nurses and other healthcare providers.

Dystocia

• Dystocia, or difficult labor, arises from the "four Ps": powers, passenger, passageway, and psyche.
• Problems with the powers involve ineffective uterine contractions (primary or secondary) or ineffective maternal pushing effort.
• Protracted disorders include slower than normal labor progress.
• Arrest disorders involve complete cessation of uterine contractions.
• Hypertonic uterine dysfunction: uncoordinated, painful, frequent contractions that do not cause cervical dilation or effacement.
• Hypotonic uterine dysfunction: weak, inefficient contractions or complete cessation.
• Ineffective maternal pushing can result from incorrect techniques, fear of injury, or decreased sensorimotor function from regional anesthesia.
• Problems with the passenger include fetal size (macrosomia), fetal malpresentation, fetal malposition, or multifetal pregnancy.
• Fetal macrosomia (birth weight > 4,000 g) complicates vaginal birth, increasing the risk of shoulder dystocia, injuries, and postpartum hemorrhage.
• Fetal malpresentation (breech, transverse) and malposition (occiput posterior) can lead to dysfunctional labor and the need for operative delivery.
• Multifetal pregnancy often results in uterine overdistention and increases the risk of abnormal presentations.
• Problems with the passageway involve obstructions in the maternal bony pelvis or soft tissues that impede fetal descent.
• Pelvic contractures: narrowing of the pelvic diameters that can hinder fetal passage.
• Soft tissue obstructions can include a full bladder or bowel or a cervical edema.
• Problems with the psyche include maternal anxiety, stress, or fear, which can release hormones that inhibit uterine contractions.
• Nursing actions for dystocia include promoting labor progress, providing physical and emotional comfort, and monitoring for complications.
• Encourage frequent position changes to promote fetal descent and relieve maternal fatigue.
• Assist with medical interventions such as oxytocin augmentation or operative vaginal birth.
• Provide continuous labor support to reduce anxiety and promote relaxation.

Preterm Labor

• Preterm labor is defined as labor that occurs between 20 and 37 weeks of gestation.
• Risk factors include a prior preterm birth, multifetal gestation, uterine abnormalities, infections, and certain medical conditions.
• Signs and symptoms of preterm labor include regular uterine contractions, pelvic pressure, backache, vaginal discharge, and cramping.
• Diagnosis is based on gestational age, uterine activity (contractions), and cervical change (effacement or dilation).
• Fetal fibronectin (fFN) is a protein produced by fetal cells that can be detected in vaginal secretions.
• A positive fFN test between 22 and 34 weeks of gestation suggests an increased risk of preterm labor.
• Nursing responsibilities include assessing risk factors, recognizing signs and symptoms, administering tocolytic medications, and providing education.
• Tocolytic drugs, such as magnesium sulfate and nifedipine, are used to suppress uterine contractions.
• Magnesium sulfate is a central nervous system depressant that relaxes smooth muscles, including the uterus.
• Nifedipine is a calcium channel blocker that inhibits uterine contractions.
• Betamethasone, a corticosteroid, is administered to the mother to accelerate fetal lung maturity.
• Provide education on signs and symptoms of preterm labor, medication side effects, and strategies to prevent preterm birth.

Postterm Labor

• Postterm pregnancy extends beyond 42 weeks of gestation.
• Risks associated with postterm pregnancy include macrosomia, shoulder dystocia, oligohydramnios, and placental insufficiency.
• Nursing actions include fetal surveillance, monitoring amniotic fluid volume, and preparing for induction of labor.
• Non-stress tests (NSTs) and biophysical profiles (BPPs) assess fetal well-being.
• Amnioinfusion may be considered to alleviate oligohydramnios and prevent cord compression.
• Prostaglandin cervical ripening agents or mechanical methods may be used to prepare the cervix for induction.

Induction of Labor

• Induction of labor involves stimulating uterine contractions to initiate vaginal birth.
• Indications for induction include postterm pregnancy, premature rupture of membranes, maternal medical conditions, and fetal compromise.
• Contraindications to induction include placenta previa, vasa previa, transverse fetal lie, and prior classical uterine incision.
• Bishop score assesses cervical readiness for labor based on dilation, effacement, station, consistency, and position.
• Prostaglandin cervical ripening agents (misoprostol, dinoprostone) soften and thin the cervix.
• Mechanical methods (Foley catheter) can be used to dilate the cervix.
• Oxytocin is a synthetic hormone that stimulates uterine contractions.
• Nursing responsibilities include monitoring maternal and fetal responses, titrating oxytocin dosage, and managing complications.
• Monitor uterine contractions for frequency, duration, and intensity.
• Assess fetal heart rate (FHR) patterns for signs of distress.
• Monitor maternal vital signs and fluid balance.
• Complications of induction include uterine tachysystole, fetal distress, and uterine rupture.

Labor Augmentation

• Labor augmentation involves stimulating uterine contractions when spontaneous labor has failed to progress.
• Techniques for augmentation include amniotomy (artificial rupture of membranes) and oxytocin infusion.
• Monitor maternal and fetal responses to augmentation, adjusting oxytocin dosage as needed.

Obstetric Emergencies

• Obstetric emergencies require immediate recognition and intervention to prevent maternal or fetal morbidity and mortality.

Prolapsed Umbilical Cord

• Prolapsed umbilical cord occurs when the cord precedes the fetal presenting part, resulting in cord compression and fetal hypoxia.
• Risk factors include malpresentation, prematurity, and polyhydramnios.
• Nursing actions include promptly recognizing the prolapsed cord, relieving pressure on the cord, and preparing for emergency cesarean birth.
• Position the mother in knee-chest or Trendelenburg position to relieve pressure on the cord.
• Manually elevate the presenting part off the cord until delivery.
• Administer oxygen to the mother.

Shoulder Dystocia

• Shoulder dystocia occurs when the fetal anterior shoulder becomes impacted behind the maternal symphysis pubis.
• Risk factors include macrosomia, gestational diabetes, and prior shoulder dystocia.
• Signs include the "turtle sign," where the fetal head retracts back into the vagina.
• Nursing actions include assisting with maneuvers to dislodge the shoulder, such as the McRoberts maneuver and suprapubic pressure.
• McRoberts maneuver involves flexing the mother's thighs sharply onto her abdomen.
• Suprapubic pressure involves applying pressure to the maternal abdomen above the pubic bone to dislodge the fetal shoulder.

Uterine Rupture

• Uterine rupture is a tear in the uterine wall, posing a significant risk to both mother and fetus.
• Risk factors include prior cesarean birth, uterine surgery, and uterine overstimulation.
• Signs and symptoms include sudden abdominal pain, vaginal bleeding, and fetal distress.
• Nursing actions include preparing for emergency cesarean birth and providing support to the mother and family.

Amniotic Fluid Embolism

• Amniotic fluid embolism (AFE) occurs when amniotic fluid enters the maternal circulation, causing a severe allergic-like reaction.
• Symptoms include sudden respiratory distress, cyanosis, cardiovascular collapse, and coagulopathy.
• Nursing actions include providing respiratory and cardiovascular support, managing coagulopathy, and preparing for resuscitation.
• Administer oxygen, initiate cardiopulmonary resuscitation (CPR), and administer medications to support blood pressure and cardiac output.

Amnioinfusion

• Amnioinfusion is the instillation of warmed, sterile normal saline or lactated Ringer's solution into the uterus through an intrauterine pressure catheter.
• Used to treat oligohydramnios and fetal heart rate decelerations caused by cord compression.
• Nursing responsibilities include monitoring infusion rate, assessing maternal and fetal responses, and preventing complications such as uterine overdistention.