Labour and Birth at Risk

• The session concerns Labour at Risk and learning outcomes.
• The major risk factors associated with preterm labor are to be understood.
• Labor dystocia will be described.
• Nursing care and management for a trial of labor, induction and augmentation of labour, forceps- and vacuum-assisted birth, and a Caesarean birth will be delivered.

Labour and Birth at Risk

• Complications during labor increase perinatal morbidity and mortality risks.
• Complications may be anticipated or arise unexpectedly due to unforeseen factors.
• Nurses caring for high-risk clients require an understanding of the normal birth process.
• Prevent and detect deviations from normal labor and birth and implement nursing measures if complications arise.

Preterm Labour

• This includes cervical changes with uterine contractions.
• It happens between 20-37 weeks gestation.
• The rate is higher among patients younger than 18 years of age or older than 35 years.

Preterm Birth

• Any birth occurs before 37 weeks completion of pregnancy; this is regardless of the weight of the infant.

Risk factors of Preterm Labour

• History of previous spontaneous preterm birth between 16 and 36 weeks of gestation
• There could be a family history of preterm labor.
• It is more common in those of African descent.
• Genital tract infection and/or uterine anomaly are risk factors.
• Use of assisted human reproduction is a risk factor.
• Cigarette smoking, substance misuse, and periodontal disease are risk factors.
• Multifetal gestation and bleeding of uncertain origin in pregnancy are risk factors.
• Low prepregnancy weight and/or socioeconomic status are risk factors.
• Lack of access to prenatal care and high levels of personal stress in one or more domains of life are risk factors.

Symptoms of Preterm Labor

• Symptoms include infections, vaginal bleeding, hormone changes, and stretching of the uterus.
• Uterine contractions more frequent than every 10 minutes, persisting for 1 hour or more, can be a symptom.
• Uterine contractions, whether painful or painless, are symptomatic.
• Discomfort may include lower abdominal cramping similar to gas pains; may be accompanied by diarrhea.
• Dull, intermittent low back pain (below the waist) can be a sign.
• Painful, menstrual-like cramps and/or suprapubic pain or pressure is a sign.
• Pelvic pressure or heaviness; feeling that "baby is pushing down" is a sign.
• Urinary frequency and a change in the character and amount of usual discharge is a sign.
• Discharge can be thicker (mucoid) or thinner (watery), bloody, brown or colorless, increased amount, odor.

Nursing Care

• Early recognition and diagnosis is based on three major diagnostic criteria.
• Gestational age is between 20 and 36 6/7 weeks with regular uterine activity, accompanied by a cervical change.
• Initial presentation with regular contractions and cervical dilation of 2 cm or greater need to be noted.
• The goal of care is prevention via preconception counseling.
• Prenatal care includes addressing risk factors and health promoting activities such as good nutrition, exercise, stress management.
• Administration of prophylactic progesterone such as daily vaginal suppositories or creams and weekly intramuscular injections is done to decrease the rate of preterm labor and birth.

Interdisciplinary Care

• Early recognition and diagnosis relies on the three major diagnostic criteria for gestational age between 20 and 36 6/7 weeks.
• Regular uterine activity, accompanied by a cervical change and initial presentation with regular contractions and cervical dilation of 2 cm or greater are important.
• Tocolytics are used to suppress labor, though with no specific medication approved in Canada.
• Antenatal glucocorticoids are administered to accelerate fetal lung maturity by stimulating fetal surfactant production.
• Magnesium sulfate may be administered to reduce or prevent newborn neurological morbidity.
• Nifedipine, indomethacin, and magnesium sulfate are used in the management of inevitable preterm birth.

Education for the Patient

• Educate patients about early symptoms of preterm labor, advise they stop what they are doing, and empty their bladder.
• Recommend drinking two to three glasses of water or juice and lying down on their side for 1 hour.
• Palpate for contractions.
• If symptoms continue, advise the patient to call their health care provider or go to the hospital.
• If symptoms go away, resume light activity but not what they were doing when the symptoms began.
• If symptoms return, call your health care provider or go to the hospital.
• If any of the following symptoms occur, call your health care provider or go to the hospital immediately.
• Uterine contractions every 10 minutes or less for 1 hour or more
• Vaginal bleeding
• Fluid leaking from the vagina

Preterm Premature Rupture of Membranes

• PROM is the spontaneous rupture of the amniotic sac and leakage of amniotic fluid beginning before the onset of labor at any gestational age.
• Preterm PROM or pPROM is the rupture of membranes before the completion of 37 weeks of gestation.
• This has approximately 10% association with all preterm births.

Risk Factors of PPROM

• A history of prior preterm birth, especially if associated with preterm PROM is a factor.
• A history of cervical surgery or cerclage (suture to keep cervix closed) can be a risk factor.
• Urinary or genital tract infection, short (<25 mm) cervical length in the second trimester identified by transvaginal ultrasound is a factor.
• Preterm labor or symptomatic contractions in the current pregnancy can be risk factors.
• Uterine overdistension is a risk factor.
• Second- and third-trimester bleeding is a risk factor.
• Pulmonary disease and connective tissue disorders are risk factors.
• Low socioeconomic status, low body mass index, and nutritional deficiencies (copper and ascorbic acid) are risk factors.
• Cigarette smoking is a risk factor.

Interdisciplinary Care

• Care is based on estimated risk of maternal, fetal, and newborn complications.
• Term pregnancy includes induction if labor begins spontaneously.
• Conservative management occurs at 34-36 weeks if there is a low risk of intrauterine infection.
• Expectant or conservative care before 32 weeks allows fetal lung maturity and complication associated with preterm birth.
• Not recommended if there is intrauterine infection, significant vaginal bleeding, placental abruption, advanced labor, or atypical or abnormal fetal assessment.
• Nonstress tests (NST) and biophysical profiles (BPP) determine fetal health status and estimate amniotic fluid volume.
• An antenatal corticosteroid is administered to patients at 24 to 34 + 6 weeks gestation.
• A 7-day course of broad-spectrum antibiotics (e.g., ampicillin/amoxicillin and erythromycin) is given.
• Magnesium sulfate is given for fetal neuroprotection in preterm PROM less than 34 weeks of gestation.

Nursing Care

• Support of the patient and family is critical at this time due to anxiety about the health of the baby .
• They may fear they are responsible in some way for the membrane rupture.
• Encourage expression of feelings and concerns and provide information.
• Inform the patient to count fetal movements daily, because a slowing of fetal movement is a precursor to severe fetal compromise.
• Patients should feel six movements in 2 hours; if they do not, further antenatal testing (NST, BPP, or both) is required.
• Monitor and educate on signs of infection; this is a major part of nursing care and patient education after preterm PROM.
• Foul-smelling vaginal discharge, maternal and fetal tachycardia should be reported immediately to the primary health care provider.
• Educate the patient to keep the genital area clean and that nothing should be introduced into the vagina.

Complications of PROM

• Maternal complications can include chorioamnionitis, which is a bacterial infection of the amniotic cavity.
• is is the most common maternal complication of preterm PROM and is associated with prolonged membrane rupture.
• This can include multiple vaginal examinations.
• It is also associated with using internal FHR and contraction monitoring modes plus young maternal age.
• Low socioeconomic status and nulliparity are associated with complications.
• Pre-existing infections of the lower genital tract are associated with complications. Management -intravenous (IV) broad-spectrum antibiotics (ampicillin and gentamicin)
• Clindamycin or metronidazole (Flagyl) after c-section can be used for management.
• The treatment is for placental abruption and retained placenta and hemorrhage Sepsis and death.
• Fetal complications include intrauterine infection and cord prolapse.
• Umbilical cord compression can be associated with oligohydramnios.

Post Term or Postdate Pregnancy

• This is a pregnancy that goes beyond the end of week 42 of gestation, or more than 294 days from the first day of the last menstrual period (LMP).

Risk Factors

• Those with first pregnancy, prior post-term, pregnancy with a male fetus, or obesity have are risk factors..
• Those with a genetic predisposition also have a higher risk.

Maternal Risks

• Labour dystocia and severe perineal injuries are risk factors.
• Chorioamnionitis, endomyometritis, and postpartum hemorrhage are risk factors.
• Caesarean birth and anxiety are risk factors.
• There is a significant risk for morbidity during the intrapartum period.

Fetal Risks

• Macrosomia or small for gestational age and shoulder dystocias are fetal risks.
• Birth trauma and asphyxia are fetal risks.
• Oligohydramnios-common, cord compression, and abnormal FHR are fetal risks.
• There is a risk compromise fetal due to "aging" placenta and stillbirth.
• Meconium-stained amniotic fluid, meconium aspiration, low Apgar scores, and convulsions in the newborn are fetal risks.

Collaborative Care

• Antepartum fetal assessment begins at 41 weeks of gestation.
• Includes daily fetal movement counts, NSTs, AFV assessments, contraction stress tests, BPPs, and Doppler flow measurements
• Patients require teaching.
• They should perform daily fetal movement counts
• They should assess for signs of labor.
• A primary health care is requried if membranes rupture or if there is a decrease in or no fetal movement.
• Keep appointments for fetal assessment tests or cervical checks.
• To go to the hospital soon after labor begins
• Birth is recommended after 42 weeks and by 42 + 6 weeks of gestation to decrease the risk for perinatal morbidity and mortality.

Dystocia

• Is abnormally slow progress of labor.
• There is greater than 4 hours of less than 0.5 cm per hour of cervical dilation in active labor OR greater than 1 hour of active pushing with no descent

Causes-Five P's of Labour

• These include ineffective uterine contractions or bearing-down efforts (the powers) which are the most common cause of dystocia.
• Alterations in the pelvic structure, including abnormalities of the laboring patient's bony pelvis or soft-tissue abnormalities of the reproductive tract.
• Fetal causes include abnormal presentation or position, anomalies, excessive size, and number of fetuses (the passenger).
• Position of patient during labor and birth is a cause.
• Psychological responses of the patient to labor are related to past experiences, preparation, culture and heritage, and support system

Nursing Care

• Supportive care by a nurse is important.
• The health care team approach with electronic fetal monitoring (EFM) and ultrasonography (to identify potential labour complications related to the fetus) is important.
• Risk assessment is a continuous process to identify dysfunctional labor and prevention.
• Interventions are based on assessment and may include external cephalic version and cervical ripening.
• Induction or augmentation of labor may be indicated.
• Operative procedures such as forceps- or vacuum-assisted birth or Caesarean birth may be necessary.

Complications of Labour Dystocia

• Fetal distress is a potential complication.
• Risk of maternal and neonatal infection, as well as postpartum hemorrhage, are potential complications.
• Uterine rupture is another potential complication.
• Increased risk of pelvic floor, genital, perineal trauma is a complication.
• Sacroiliac joint dislocation and increased risk of uterine or pelvic organ prolapse can occur.
• There is an increased risk of obstetrical fistula such as vesico-vaginal or rectovaginal fistula, and incontinence.

Prolapsed Umbilical Cord

• Nursing care focuses on management of cord prolapse by relieving pressure on the cord.
• By elevation of the fetal presenting part, knee-to-chest position, and manual decompression by health care by gentle elevation of the presenting part off the umbilical cord.
• It involves placing the client in a Trendelenburg or knee-chest position to aid in cord decompression.
• Tocolytics slow down uterine contractions to relieve pressure on the umbilical vessels and to improve placental perfusion.
• The nurse should keep the protruding cord warm and moist to prevent vasospasm of the umbilical arteries, contributing to fetal hypoxia.
• Continuous fetal monitoring should be done.
• A Caesarean section is indicated if the cervix is not fully dilated or if there is a risk of fetal compromise.
• Patients should recognize cord prolapse as a sudden gush of fluid followed by the feeling of vaginal pressure or fullness.
• They should seek immediate care and assume a knee-chest position while waiting for help to arrive.

Shoulder Dystocia

• This is a condition in which the head is born but the anterior shoulder cannot pass under the pubic arch.
• It is a Fetopelvic disproportion caused by excessive fetal size greater than 4 000 g.
• Macrosomia and/or pelvic abnormalities can cause this.
• Prolonged second stage of labor and a history of shoulder dystocia with a previous birth put someone at risk.

Collaborative Care

• First-line interventions include the McRoberts maneuver in which legs are hyperflexed on the abdomen.
• Apply suprapubic pressure over the anterior shoulder – fundal pressure should be avoided
• Implement the Gaskin manoeuvre by placing patient in all position with hands-and-knees.

Complications

• Complications can include brachial plexus (Erb palsy) which occurs in 10 to 20% of cases.
• Phrenic nerve injuries, as well as fracture of the humerus or clavicle, can also occur.
• Asphyxia is a possible complication.

Amniotic Fluid Embolism (AFE) or Anaphylactoid Syndrome of Pregnancy

• Involves the introduction of amniotic fluid into the circulation of the laboring patient during labor, during birth, or within 30 minutes after birth.
• The patient experiences respiratory distress and restlessness, dyspnea, cyanosis, or pulmonary edema; It can go to respiratory arrest.
• In circulatory collapse there is hypotension and tachycardia leading to shock or cardiac arrest.
• Hemorrhage and coagulation failure as well as uterine atony are symptoms of AFE.
• The mortality rate is 61% or higher

Risk Factors

• Advanced age, non-White race, placenta previa, pre-eclampsia, and forceps-assisted or Caesarean birth are risk factors.

Interventions

• In oxygenate, administer oxygen by nonrebreather face mask (10 L/min) or resuscitation bag delivering 100% oxygen.
• Prepare for intubation and mechanical ventilation.
• Initiate or assist with cardiopulmonary resuscitation.
• Tilt the pregnant patient 30 degrees to their side to displace the uterus.
• Provide fluids.
• Maintain cardiac output and replace fluid losses: Position the patient on their side.
• Administer IV fluids and blood products like packed cells and fresh frozen plasma
• Insert an in-dwelling catheter and measure hourly urine output.

Other Interventions

• Correct coagulation failure and monitor fetal and maternal status.
• Prepare for emergency birth once the patient's condition has stabilized.
• Provide emotional support to the patient, partner, and family.

Induction of Labour

• This includes chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about the birth.
• High-priority indications include preeclampsia > 37 weeks and significant maternal disease not responding to treatment.
• Significant but stable antepartum hemorrhage, chorioamnionitis, and suspected fetal compromise are other priority factors.
• Consider term prelabor rupture of membranes with maternal group B streptococcus (GBS) colonization.

Other Indications

• Postdates (> 41 + 0 weeks) or post-term (> 42 + 0 weeks) pregnancy are considered for induction.
• Those with uncomplicated twin pregnancy > 38 weeks should be considered.
• Diabetes mellitus (glucose control may dictate urgency) and alloimmune disease at or near term.
• Intrauterine growth restriction or oligohydramnios

Contraindications

• Gestational hypertension > 38 weeks and intrauterine fetal death mean induction is contraindicated..
• PROM near or at term (GBS negative) is a contrary factor.
• Logistical issues as indicated by a history of fast labor or distance from the hospital are a factor.
• Caregiver or patient convenience also affects whether induction happens.
• Intrauterine demise is a good indication in a previous pregnancy to allay anxiety.
• Suspected fetal macrosomia and an absence of fetal or maternal indication are contraindications.

Cervical Ripening Agents

• Chemical agents can be used to ripen the cervix, making it softer and causing it to begin to dilate and efface.
• It stimulates uterine contractions.
• Prostaglandins E2 include the Cervidil insert that is placed transvaginally into the posterior fornix of the vagina; this is removed after 12 hours or at the onset of active labor or abnormal fetal heart rate and patterns occur.
• Prepidil Gel is administered through a syringe into the vaginal canal just below the internal cervical os.
• Adverse effects as well as patient and family education is key.
• Nurses should explain the procedure and obtain informed consent; they should assess the patient and fetus before each insertion and during treatment.

Other considerations

• Prepidil gel should be brought to room temperature just before administration and it should be kept the Cervidil insert frozen until just before insertion.
• Patients need to void before insertion and maintaining a supine position with lateral tilt for at least 30 minutes after insertion.
• Prepare to pull the string to remove the insert if significant adverse effects occur and follow agency protocol for induction if ripening has occurred.

Mechanical Dilation

• Using mechanical dilators to ripen the cervix will stimulate the release of endogenous prostaglandins.
• Balloon catheters are inserted through the intracervical canal
• The catheter balloon is inflated above the internal cervical os with 30 to 50 mL of sterile water.
• The resulting pressure and stretching of the lower uterine segment and the cervix which stimulate the release of endogenous prostaglandins.
• The balloon will fall out when cervical dilation reaches approximately 3 cm or is removed after 24 hours have elapsed.
• Contraindications include low-lying placenta, antepartum hemorrhage, and rupture of membranes.
• Evidence of lower tract genital infection is another contraindication.
• Hydroscopic dilators and substances that absorb fluid from surrounding tissues and enlarge are used.
• These include Laminaria tents, which are natural cervical dilators made from desiccated seaweed
• Lamicel synthetic dilators absorb fluid expanding the cervix.

Mechanical and Physical Methods of Induction

• Sexual intercourse which includes prostaglandins in the semen and stimulation of contractions with orgasm is used.
• Nipple stimulation releases endogenous oxytocin from the pituitary gland.
• Ambulation and walking apply pressure to the cervix, which stimulates the secretion of endogenous oxytocin.

Alternative and Amniotomy

• Amniotomy is artificial rupture of membranes [AROM] indicated when the presenting part of the fetus should be engaged and well applied to the cervix.
• There can be no active infection of the genital tract (e.g., herpes) and HIV status should be negative or viral load is low.
• Labour usually begins within 12 hours of the rupture.
• It is difficult to predict outcome of labor and time of birth after amniotomy and combination with oxytocin inductions is useful.
• Assess amniotic fluid for color, odor, amount, and consistency for meconium or blood.
• Blue cohosh and castor oil for labor-stimulation effects while black cohosh and evening primrose oil ripen the cervix, but these alternative methods are not well researched

Complications of Amniotomy

• Chorioamnionitis can results from prolonged rupture without labor.
• Variable FHR deceleration patterns occur due to cord compression resulting from umbilical cord prolapse or decreased amniotic fluid.

Oxytocin

• Is a medication that stimulates uterine contractions.
• This used for induction or augmentation of labor.
• Administered IV in saline or lactated Ringers via a pump.
• Administration aims to produce acceptable uterine contractions as evidenced by a consistent pattern of three to five contractions every 10 minutes.

Common Indications for Oxytocin

• Suspected fetal jeopardy and inadequate uterine contractions that cause dystocia.
• Prelabor rupture of membranes.
• Post-term pregnancy, chorioamnionitis, and medical concerns in pregnant patient.
• Gestational hypertension (e.g., pre-eclampsia, eclampsia) and fetal death are other indications.

Contraindications

• Include abnormal fetal heart rate, cephalopelvic disproportion, prolapsed cord, or transverse lie.
• Placenta previa or vasa previa, a prior classic uterine incision or other uterine surgery, active genital herpes infection, invasive cancer of the cervix, and previous uterine rupture

Conditions Requiring Report

• Uterine tachysystole (with or without FHR changes)
• Abnormal fetal heart rate and pattern such as absent baseline variability and any of the following:
• Recurrent late decelerations, recurrent variable decelerations, bradycardia, prolonged decelerations

Nursing Care During Oxytocin Administration

• Nurses should assess the level of the laboring patient's discomfort and pain and the effectiveness of pain management.
• They should also monitor fetal status using electronic fetal monitoring and carefully evaluate tracing.
• Monitoring should occur every 15 minutes with every change in dose during the first stage of labor as well as during the active pushing phase of the second stage.
• The contraction pattern and uterine resting tone should be observed for every 15 minutes and with every change in dose during delivery.
• Monitor blood pressure, pulse, and respirations every 30 to 60 minutes.
• Assess patient's intake and limit IV intake to 1 000 mL in 8 hours.
• Urine output should be 120 mL or more every 4 hours as well.

Adverse Effects

• Monitor for adverse effects, including nausea, vomiting, headache, and hypotension, and observe emotional responses of laboring patient and their partner.
• Report any conditions such as discontinuing use of oxytocin per hospital protocol and notify primary care provider immediately.
• Turn the patient onto lateral position and give IV bolus if patient is hypovolemic or hypotensive.
• Administer oxygen by nonrebreather face mask at 8 to 10 units/min or per protocol or primary health care provider's order.