Obstetrics and Delivery

• Chapter 8 focuses on Nursing Care of Patients with Complications During Labor and Birth

Lesson 8.1 Objectives

• The Key words listed in chapter 8 must be defined
• Obstetric procedures are discussed
• Analyze the nurse's role during obstetric procedures
• Analyze the nurse's role in a cesarean birth

Obstetric Procedures

• Amnioinfusion involves the infusion of a sterile solution of fluid into the amniotic cavity
• A version is a procedure used to turn the fetus from one presentation to another
• Induction encourages the start of labor
• Augmentation assists with the progress of labor that has already started

Bishop Scoring System

• Used for determining the readiness of the cervix for labor
• It measures how ready the cervix is
• Dilation scores range from Closed to 5-6 cm
• Position of cervix ranges from Posterior to Anterior
• Effacement scores range from 0-30 to 80%
• Station scores range from -3 to +2
• Cervical consistency ranges from Firm, Medium and Soft
• Higher scores indicate a greater likelihood of successful induction

Indications for Labor Induction

• Maternal health conditions may suggest need for Induction
• Gestational hypertension, Preeclampsia or Eclampsia
• Ruptured membranes without the spontaneous onset of labor
• Especially if the patient is GBS positive
• Infection within the uterus
• Chorioamnionitis
• Medical problems in the patient that worsen during pregnancy
• Diabetes, ESRD and other chronic conditions
• Fetal problems such as slowed growth, prolonged pregnancy, or incompatibility between fetal and maternal blood types
• Placental insufficiency
• Fetal death

Contraindications to Induction

• Include placenta previa
• The presence of an umbilical cord prolapse
• An abnormal fetal presentation
• High station of the fetus
• Active herpes infection in the birth canal
• Abnormal size or structure of the patient's pelvis
• Previous classical cesarean incision

Augmentation

• Labor has begun spontaneously, but has fizzled out
• Maternal/fetal health concern
• Natural, pharmacological, and mechanical interventions are available

Pharmacologic Methods to Stimulate Contractions

• Cervical ripening helps to soften and prepare the cervix for labor
• Prostaglandin E₂ Cervidil (Dinoprostone) is administered through intravaginal insertion
• It provides a sustained release of medication, typically overnight
• Prostaglandin E₁ Cytotec (Misoprostol) is administered through intravaginal insertion or PO
• Cytotec is considered more effective at producing vaginal delivery within 24 hours
• Pitocin is used to stimulate uterine contractions in both induction and augmentation of labor
• Pitocin is administered intravenously through titrated doses
• A primary risk of Pitocin is uterine tachysystole or tetany

Preparing the Patient for Labor Augmentation

• Explain the procedure
• Obtain baseline vital signs and fetal heart rate
• Ensure an IV line is placed
• The patient must remain in bed for 2 hours
• Pitocin induction can start 6 to 12 hours after vaginal insert has been removed
• Assess for signs of uterine tachysystole

Dilating the Cervix

• Stripping amniotic membranes helps to stimulate labor
• Hydroscopic dilators are used to gradually dilate the cervix
• Transcervical balloon dilators help to dilate the cervix mechanically

Amniotomy

• This is the artificial rupture of membranes (AROM)
• Used to stimulate or enhance contractions
• Commits the patient to delivery
• The procedure stimulates prostaglandin secretion
• The patient is carefully monitored for potential complications
• Prolapse of the umbilical cord, infection, abruptio placentae

Complications Associated with Amniotomy

• Prolapsed umbilical cord
• Infection
• Abruptio placentae

Nonpharmacologic Methods to Stimulate Contractions

• Walking stimulates contractions, eases pressure, adds gravity
• Semen deposit on cervix but is not safe in already ruptured membranes
• Nipple stimulation via suckling causes the pituitary gland to secrete natural oxytocin

Obstetric Version

• This is a method used to change the fetal presentation
• Two methods for obstetric version
• External, usually performed at 37 weeks' gestation but before the onset of labor
• Internal, emergent, during active labor

Risks and Contraindications to Obstetric Version

• Disproportion between patient's pelvis and fetal size
• Abnormal uterine or pelvic size or shape
• Abnormal placental placement
• Previous cesarean birth with vertical uterine incision
• Active herpes virus infection
• Inadequate amniotic fluid
• Poor placental function
• Multifetal gestation
• Fetus can become entangled in umbilical cord

Episiotomy

• Controlled surgical enlargement of the vaginal opening during birth
• Better control over where and how much the vaginal opening is enlarged
• Results in an opening presents a clean edge rather than the ragged opening with a tear
• Note: Perineal massage and stretching exercises before labor may be an alternative

Perineal Lacerations

• Uncontrolled tearing of perineal tissue
• First degree: superficial vaginal mucosa or perineal skin
• Second degree: involves vaginal mucosa, perineal skin, and deeper tissues of the perineum
• Third degree: same as second degree, plus involves anal sphincter
• Fourth degree: extends through the anal sphincter into the rectal mucosa

Forceps Extraction

• Provides traction and rotation of the fetal head when the patient's pushing efforts are insufficient
• Used during the end of the second stage of labor in vaginal delivery
• Also used during cesarean birth to extract the fetal head through the incision

Vacuum Extraction Birth

• Uses suction applied to the fetal head during the mother's expulsive efforts
• Vacuum extraction is only with occiput presentation and at end of second stage of labor

Risks of Forceps or Vacuum Extraction

• Trauma to maternal or fetal tissues
• The patient may have a laceration or hematoma in their vagina
• Infant can have bruising, facial or scalp lacerations or abrasions, cephalohematoma, or intracranial hemorrhage

Cesarean Birth Indications

• Abnormal labor
• Inability of the fetus to pass through the maternal pelvis
• Maternal conditions such as GH or DM
• Active maternal herpes virus
• Previous surgery on the uterus
• Fetal compromise
• Placenta previa or abruptio placentae

Preparation for Cesarean Birth

• Clinical lab studies to identify anemia and blood-clotting abnormalities
• CBC, coagulation studies, blood type & cross
• Baseline vital signs, including fetal heart rate
• Patient positioning for comfort
• IV line placement
• Foley catheter insertion

Types of Incisions

• Skin incisions can be vertical, allowing more room for a large fetus
• Transverse skin incisions, also known as Pfannenstiel incisions, are more common
• Uterine incisions can be low transverse, which is not likely to rupture during another birth, making VBAC possible
• Low vertical incisions have minimal blood loss but are more likely to rupture during another birth
• Classic uterine incisions are rarely used, result in more blood loss and are most likely to rupture during another pregnancy

Nursing Care in the Recovery Room

• Measure vital signs to identify hemorrhage or shock
• Assess IV to determine the site and rate of solution flow
• Check the fundus for firmness, height, and midline position
• Change dressing for drainage
• Assess lochia for quantity, color, and the presence of clots
• Measure urine output from the indwelling catheter

Lesson 8.2 Objectives

• Describe factors that contribute to an abnormal labor
• Explain each intrapartum complication

Abnormal Labor

• Also referred to as dysfunctional labor or dystocia
• Characterized by a labor that does not progress or is difficult

Problems with the Powers of Labor

• Labor contractions can either present as hypertonic
• Or hypotonic

Ineffective Maternal Pushing

• The woman may not understand which technique to use or fears tearing her perineal tissues
• Epidural or subarachnoid blocks may depress or eliminate the natural urge leading to ineffective pushing
• An exhausted woman may be unable to gather enough of energy to push

Problems with the Fetus

• The passenger, or the fetus, may cause the labor's progression to be dysfunctional
• This can be due to size, presentation, positioning and birth defects
• Another factor may be multifetal pregnancies

Abnormal Fetal Presentation or Position

• Prevents the smallest diameter of the fetal head to pass through the smallest diameter of the pelvis

Nursing Care for Abnormal Fetal Presentation or Positions

• Encourage patients to assume positions that favor fetal rotation and descent and reduce back pain
• Sitting, kneeling, or standing while leaning forward
• Rocking the pelvis back and forth while on hands and knees, encourages rotation
• Side-lying, Squatting in second stage of labor
• Lunging by placing one foot in a chair with the foot and knee pointed to that side

Multifetal Pregnancy

• may cause dysfunctional labor
• Uterine overdistension can lead to poor contraction quality
• Abnormal presentation or position of one or more fetuses interferes with labor mechanisms
• Often, one fetus is delivered as cephalic and the second is breech unless a version is done

Problems with the Pelvis and Soft Tissues

• The bony pelvis can lead to problems in labor
• Gynecoid pelvis is the most favorable for vaginal birth
• Soft tissue obstructions can lead to problems in labor
• Most common is a full bladder

The Psyche

• Most common factors that can prolong labor
• Lack of analgesic control leading to excessive pain
• Absence of a support person or coach
• Immobility and restriction to bed
• Lack of ability to carry out cultural traditions

Effects of Hormones Released

• The uterus uses more glucose for energy
• Diverts blood from the uterus
• Increases tension of pelvic muscles, so can impede fetal descent
• Increases perception of pain

Abnormal Duration of Labor

• Friedman curve is often used to graph the progress of cervical dilation and fetal descent
• It is used as a guide to assess and manage the normal progress of labor
• Prolonged labor can cause maternal or newborn infection, maternal exhaustion, postpartum hemorrhage and/or greater anxiety and fear

Precipitate Birth

• Rapid birth that is completed in less than 3 hours from labor onset
• Labor begins abruptly and intensifies quickly with frequent and possibly intense contractions
• They have the potential for uterine rupture, cervical lacerations, or hematoma
• Fetal oxygenation may be compromised
• Rapid birth can lead to birth injuries may, like intracranial hemorrhage or nerve damage

Premature Rupture of Membranes (PROM)

• Spontaneous rupture of membranes at term, more than 1 hour before labor contractions begin
• Vaginal or cervical infection may cause PROM
• PROM confirmed by Nitrazine paper test and looking for a "ferning" pattern from vaginal fluid placed on a slide and viewed under the microscope

Patient Teaching for a Woman with an Infection or in Preterm Labor

• Report a temperature that is above 38°C (100.4°F)
• Avoid sexual intercourse or insertion of anything into the vagina
• Refrain from orgasms or breast stimulation
• Maintain any activity restrictions prescribed
• Note any uterine contractions, reduced fetal activity, and other signs of infection
• Record fetal kick counts daily and report fewer than 10 kicks in a 12-hour period

Preterm Labor Risk Factors

• Exposure to DES
• Underweight
• Chronic illness
• Dehydration
• Preeclampsia
• Previous preterm labor or birth
• Previous pregnancy losses
• Substance abuse
• Chronic stress
• Infection or Anemia
• Preterm PROM
• Inadequate prenatal care
• Poor nutrition
• Low education level
• Poverty or Smoking
• Multifetal presentation

Signs of Impending Preterm Labor

• A shortened cervix on ultrasound at 20 weeks may be predictive of preterm labor
• Diagnosis based on cervical effacement and dilation of more than 2 cm
• A fibronectin test may be predictive of preterm labor
• Fibronectin leaks into vaginal secretions when uterine activity, infection, or cervical effacement occurs
• Fibronectin in vaginal secretions between 22 and 24 weeks' gestation may be predictive of preterm labor

Maternal Symptoms of Preterm Labor

• Can include contractions that may be either uncomfortable or painless
• Feeling that the fetus is "balling up" frequently
• Menstrual-like cramps or constant low backache
• Pelvic pressure or feeling that the fetus is pushing down
• A change in vaginal discharge, abdominal cramps with or without diarrhea
• Pain or discomfort in the vulva or thighs
• "Just feeling bad" or "coming down with something"

Tocolytic Therapy

• Goal is to stop uterine contractions
• Keep fetus in utero until lungs are mature enough to adapt to extrauterine life
• Magnesium sulfate (IV), beta-adrenergic (PO), calcium channel blockers (PO) can be used
• Prostaglandin synthesis inhibitors

Tocolytic Therapy Contraindications

• Preeclampsia
• Placenta previa
• Abruptio placentae
• Gestational age over 37 weeks
• Chorioamnionitis
• Fetal demise

Stopping Preterm Labor

• Initial measures include treating infections and maintaining hydration
• Patients should be sent home with strict return instructions and activity restrictions
• Secondary drug therapy involving oral or IV treatments
• If preterm birth appears inevitable, steps are taken to speed up fetal lung maturity
• Amniocentesis is performed to assess fetal maturity
• Steroids are administered to increase fetal lung maturity
• Thyroid-releasing hormone also enhances lung maturity in fetuses younger than 28 weeks

Antenatal Corticosteroids

• A single course reduces the risk of serious respiratory illness and death in neonates in low-middle- and high- income countries
• Insufficient data for high-risk pregnancies with multiple babies or diabetes/hypertension

Prolonged Pregnancy

• Considered to last longer than 41 weeks
• Placenta ages and delivers oxygen and nutrients to the fetus less sufficiently
• Fetus may lose weight and skin may peel
• The baby is born larger than average
• Continued growth past full term
• Meconium may be expelled
• May lead to low blood glucose levels in the fetus

Tests Used to Confirm the Diagnosis of Prolonged Pregnancy

• Any pregnancy that lasts longer than 40 weeks may require testing
• Nonstress tests (NST) should be required
• Amniotic fluid index (AFI)
• Biophysical profile (BPP)
• Kick counts

Lesson 8.3 Objectives

• Discuss the nurse's role in caring for women having each intrapartum complication
• Review the nurse's role in obstetric emergencies

Emergencies During Birth

• Include a prolapsed umbilical cord or a placenta accreta
• A prolapsed umbilical cord can be complete, palpated, or occult
• Placenta accreta

Emergencies During Childbirth

• Include a potential uterine rupture
• Symptoms of a uterine rupture include sharp abdominal and chest pain
• Changes in belly shape or loss of contractions

Amniotic Fluid Embolism

• Occurs when amniotic fluid with particles like vernix and fetal hair, enter a woman's circulation and obstruct small blood vessels
• Characterized by abrupt onset of hypotension, respiratory distress, and coagulation abnormalities

Definitions

• Artificial rupture of membranes: Intentional puncture of the amniotic sac and release of amniotic fluid for the purpose of inducing or augmenting labor

• Augmentation of labor: Enhancement of labor after it has begun; the simulation of contractions after they have begun naturally

• Bishop score: A scoring system determining if labor can be safely induced

• Cephalopelvic disproportion: Condition in which the fetus cannot pass through the maternal pelvis

• Chignon: Newborn scalp edema created by a vacuum extractor

• Chorioamnionitis: Intrauterine infection during pregnancy

• Dysfunctional Labor: Ineffective labor pattern that will not effectively deliver the infant

• Shoulder dystocia: Anterior fetal shoulder becomes stuck on the maternal pubic symphysis, delaying baby's birth

• Hydramnios: A condition in which there is too much amniotic fluid

• Induction of labor: To cause labor to begin

• Macrosomia: An abnormally large infant, or neonatal birth weight above the 90th percentile

• Oligohydramnios: A condition in which there is not enough amniotic fluid around the fetus

• Oxytocics: Drugs intensifying uterine contractions to hasten birth or control postpartum hemorrhage

• Tocolytics: Drugs reducing uterine contractions, used to delay labor onset and prevent pre-term delivery

• Spontaneous rupture of membranes: Rupture of fetal membranes occurring on its own

• Version: Turning of the position of the fetus in the uterus before birth

• Tachysystole: Too-frequent uterine contractions

Review of obstetrics and delivery including bishop scores, labor induction, and potential complications. Covers contraindications, risks, and interventions during childbirth. Focuses on maternal and fetal well-being during labor and delivery.