Labor and Birth Risks

Learning Outcomes

• Dystocia's primary causes along with associated nursing and medical interventions should be described
• Potential complications of dystocia in labor including required nursing and medical interventions should be identified
• Knowledge related to the induction and augmentation of labor along with vaginal birth after cesarean section should be demonstrated
• Identification and management of high-risk pregnancy, labor, and delivery to promote healthy outcomes for the mother and infant
• Key obstetric emergencies and their related nursing and medical interventions should be described

Labor and Birth at Risk

• In the event of complications, perinatal morbidity and mortality risks increase
• Some complications can be anticipated, especially when the mother has been identified as high risk
• Other complications can be unexpected or unforeseen
• It is crucial for nurses to understand the normal birth process, prevent and detect deviations from normal labor and birth, and implement nursing measures if complications arise
• Nurses and obstetric teams should work together to care in the event of complications

Preterm Labor and Birth

• Characterized by regular uterine contractions with cervical effacement and dilation between 20 and 37 weeks of gestation
• It is one of the most common obstetric complications that, if not stopped, can lead to preterm birth

Preterm Labor and Birth Risk Factors

• 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

Predicting Spontaneous Preterm Labor and Birth: Assessment

• Need an assessment of risk factors
• Change in vaginal discharge
• Pelvic pressure
• Low back ache
• Cervical length
• Fetal fibronectin (fFN)
• More than six contractions in an hour
• Four contractions every 20 minutes or eight contractions in one hour

Preterm Labor: Nursing Assessment

• During assessment you should be aware of risks
• Lab and diagnostic testing
• Laboratory and diagnostic information to consider: CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length measurement via transvaginal ultrasound, and cervical culture
• Early recognition and diagnosis are key interventions for prevention
• Lifestyle modifications also constitute prevention, including activity and restriction of sexual activity

Suppression of Uterine Activity

• Tocolytic therapy: this can stop uterine contractions and usually only delays delivery
• Magnesium Sulfate: relaxes the smooth muscle of the uterus
• Brethine (Terbutaline): Beta-adrenergic
• Nifedipine (Procardia): Calcium channel blocker
• Indomethacin (Indocin): Prostaglandin synthesis inhibitor
• Corticosteroid (Betamethasone) promotes fetal lung maturity
• Immediate care and assessment of mother and fetus are important
• Have Calcium Gluconate available if administering Magnesium Sulfate
• Discharge teaching should include teaching warning signs of preterm labor
• Prophylactic antibiotics are indicated for women with group B streptococcus

Prelabor Rupture of Membranes (PROM)

• Defined as the rupture of the amniotic sac and leakage of amniotic fluid beginning at least one hour before the onset of labor at any gestational age
• Infection is a major risk factor

PROM Risk Factors

• History of preterm PROM
• Short cervical length
• Low socioeconomic status
• Smoking and illicit drug use

PROM Care Assessment and Interventions

• Determine the estimate of risk for each woman
• Monitor the fetal heart rate and maternal vital signs, especially temperature
• The greatest risk is infection
• Assess labs (CBC) for signs of infection
• Labor may need to be induced
• Hospitalization is usually needed

Chorioamnionitis

• Characterized by bacterial infection of the amniotic cavity and inflammation of fetal amnion and chorion membranes with bacteria ascending into the uterus from the vagina
• Prolonged rupture of membranes, multiple vaginal exams, and the use of internal fetal monitoring are risk factors
• Signs/Symptoms include maternal fever >100.4, maternal and fetal tachycardia, uterine tenderness, and foul-smelling amniotic fluid
• Treatment is IV broad-spectrum antibiotics (PCN, ampicillin) and you may send the placenta to pathology
• Follow-up with neonate will include blood cultures and IV antibiotics until blood culture results
• Communicate findings, assess for maternal WBC greater than 15,000, administer antibiotics and antipyretics as ordered

Post-Term Pregnancy

• Post-term pregnancy is one that has completed 42 weeks of gestation
• This has unknown etiology, so a review of estimated date of delivery (EDD) is needed
• Large fetus, increased risk for Cesarean birth, dystocia, birth trauma, postpartum hemorrhage, and infection are indications of maternal risks
• Increased risk for forcep or vacuum-assisted birth, and/or induction of labor
• Fetal risks may include: Macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, decreased perfusion, meconium staining, and cephalopelvic disproportion
• As the placenta ages, perfusion decreases

Postterm Pregnancy: Assessment & Management

• Note estimate date of birth
• Monitor daily fetal movement
• Nonstress tests are done twice weekly
• Weekly cervical exams
• Biophysical profile and Amniotic Fluid Index (AFI)
• Assess client understanding
• If the determined plan is to wait, then fetal surveillance is key

Dystocia

• Dystocia indicates cases of difficult labor or "failure to progress"
• Often the reason for cesarean sections
• Factors influencing labor are referred to as the 5 "P's" with a focus on abnormalities of:
  • Powers (ineffective uterine contractions and maternal pushing)
  • Passage (alterations in the pelvic structure)
  • Passenger (fetal causes such as fetal presentation)
  • Position (maternal position during labor)
  • Psychologic (response of the woman)
• Early identification and interventions for dystocia are important to minimize maternal and fetal risk

Uterine Dystocia: Problems With the Powers

• Hypertonic uterine dysfunction is when the uterus does not fully relax between contractions
• Hypertonic dystocia is associated with induction/augmentation, tachysystole, and abruption
• Assessment involves frequent contractions, inadequate resting tone, little cervical changes, and a possible Category II or III FHR pattern

Hypotonic Uterine Dysfunction

• Hypotonic uterine dysfunction occurs during active labor
• Uterine contraction is insufficient (<25 mm Hg) to promote cervical dilation and effacement