Post-term Pregnancy and Labor Dystocia

Post-term Pregnancy

• ACOG 2019 recommends continuous external fetal monitoring during labor to observe sources of fetal hypoxemia, such as late decelerations from placental insufficiency or variable decelerations that can be caused by umbilical cord compression.
• Amnioinfusion can be considered when variable or prolonged decelerations suggest umbilical cord compression, as it can help increase amniotic fluid volume.

Labor Dystocia (The 5 P’s)

• Dystocia refers to a lack of progress in labor for any reason, most commonly encountered in post-term labor or cases with macrosomia.
• Dysfunctional labor describes a long, difficult, or abnormal labor caused by various conditions related to:
  • The Powers: ineffective uterine contractions or maternal pushing efforts
  • The Passage: alterations in the bony pelvic structure or soft-tissue dystocia
  • The Passenger: abnormal fetal presentation, position, congenital anomalies, or multiple fetuses
  • The Psyche: maternal position and psychologic response
  • The Position: maternal positioning during labor
• Uterine cupping can occur due to the baby being too large or positioned abnormally.

Meconium Aspiration Syndrome

• Meconium aspiration syndrome (MAS) is a condition in newborns where meconium is aspirated into the lungs, usually resulting from a prolonged intrauterine process rather than the first breath.
• The American Academy of Pediatrics (AAP) no longer recommends routine suctioning of newborns.
• Care Management for MAS often involves an interprofessional team skilled in neonatal resuscitation, supplemental oxygen, surfactant, antibiotics, and even ECMO (extracorporeal membrane oxygenation).

Birth Trauma

• Physical injuries sustained by a newborn during labor and birth are classified by etiology or location:
  • Soft-Tissue Injuries: bruising, lacerations, edema
  • Skeletal Injuries: fractures
  • Peripheral Nervous System Injuries: brachial plexus injury, Erb-Duchenne palsy, facial paralysis
  • Central Nervous System Injuries: subdural hematoma, subarachnoid hemorrhage
• Birth trauma care management is dependent upon the type of injury and involves initial and ongoing assessment, education, support, and pain management.

Shoulder Dystocia

• Occurs when the baby's head is born but the anterior shoulder cannot pass under the pubic arch, commonly associated with macrosomia, maternal pelvic abnormalities, maternal diabetes, and prolonged second stage of labor.
• Care management focuses on immediate intervention with maneuvers like the McRoberts maneuver, suprapubic pressure, and the Gaskin maneuver (hands and knees). Fundal pressure is strictly prohibited.

Prolapsed Umbilical Cord

• This occurs when the umbilical cord lies below the presenting part of the fetus, often contributing to prolonged cord compression.
• Care management involves prompt recognition of the condition and immediate action to relieve pressure on the cord via a vaginal exam. Cesarean birth or operative vaginal delivery may be necessary if the patient is fully dilated.

Uterine Rupture or Uterine Dehiscence

• Uterine rupture or dehiscence is a rare but serious complication with an incidence of approximately 1%, and significant maternal/neonatal morbidity & mortality.
• Risk factors include previous cesarean birth or uterine surgery, trauma, abortion, instrumentation injury, grand multiparity, and uterine overdistension.
• Care management involves preventing this complication through careful assessment for risk factors and avoiding the use of prostaglandins for cervical ripening.

Amniotic Fluid Embolus (Anaphylactoid Syndrome of Pregnancy)

• A sudden, acute onset of hypotension, hypoxia, and hemorrhage caused by coagulopathy.
• It is not preventable and true incidence is unknown.
• Major risk factors include maternal age >35, rapid labor, meconium-stained fluid, post-term pregnancy, instrumental labor, and operative birth.
• Onset occurs during labor, birth, or within 30 minutes of delivery.
• Care Management prioritizes resuscitation efforts with oxygenation, maintaining cardiac output, fluid replacement, and correcting coagulopathies.
• The nurse's role includes monitoring maternal/fetal status, preparing for emergency birth, and providing emotional support.

Birth Trauma Effects on Nurses

• Nurses often experience psychological trauma, decreased job performance, increased absenteeism, requests for assignment changes, and even leaving the field altogether following birth trauma cases.

Newborn Congenital Anomalies

• Congenital anomalies affect 2-3% of live births.
• The leading cause of infant deaths under 1 year of age.
• 50% of congenital defects have no identifiable cause.
• Cardiac defects are the most common congenital anomaly.

Central Nervous System Anomalies

• Encephalocele: Herniation of the brain and meninges usually found in the occipital area of the skull.
  • Often found with other congenital anomalies like cardiac, cleft lip/palate, and microencephaly.
  • Treatment involves surgery and placement of a shunt to remove excess CSF.
• Anencephaly: The most severe neural tube defect where both cerebral hemispheres and the overlying skull are absent.
  • Incompatible with life, many infants are stillborn or die after 20 weeks of pregnancy.
  • Palliative care and support for the family is crucial.

Respiratory System Anomalies

• Congenital Diaphragmatic Hernia: Intestines are located in the chest cavity, compressing the lungs.
  • Characterized by barrel chest, scaphoid abdomen, asymmetric chest expansion, respiratory distress, and bowel sounds heard in the thoracic cavity.
• Choanal Atresia: Most common nasal congenital anomaly where the posterior nares are blocked by a membrane or bone.
  • Infants experience cyanosis and retractions at rest, but color improves with crying.
  • May also present with noisy respirations, difficulty breathing during feeding, and copious/thick mucous.

Gastrointestinal System Anomalies

• Omphalocele: Herniation of abdominal contents contained in a peritoneal sac.
  • May contain intestines, liver, and spleen.
  • Associated with other congenital anomalies, chromosomal abnormalities, and risk factors including young or advanced maternal age, obesity, use of SSRIs, alcohol, and tobacco use.
• Gastroschisis: Herniation of the bowel through an abdominal wall defect.
  • Not usually associated with other congenital anomalies.
  • Risk factors include low maternal weight, IUGR, tobacco, recreational drug and antidepressant use, and exposure to agricultural chemicals.

Gastrointestinal Obstruction

• Obstructions can occur anywhere in the gastrointestinal tract.
• Symptoms include bilious emesis, abdominal distention, failure to pass meconium, and respiratory distress if the obstruction is high.

Anorectal Malformations

• Imperforate Anus: Absence of an anal opening or an abnormally located opening.
  • May be associated with a fistula to the genitourinary tract.
  • Assessment for patency is crucial.

Genitourinary System Anomalies

• Exstrophy of the Bladder: The bladder is exposed outside the body.
  • More common in males than females.
  • Often associated with epispadias and requires immediate surgical closure.

Nursing Interventions

• Central Nervous System Anomalies - Focus on family support and care post-surgery.
• Diaphragmatic Hernia - Maintain adequate respiratory status, provide gastric decompression, place the infant in high semi-Fowler's position, turn to the affected side to allow for lung expansion, and involve parents in care.
• Choanal Atresia - Pass a feeding tube to confirm the diagnosis, insert an oral airway, and keep the infant prone to prevent aspiration.
• Gastroschisis & Omphalocele - Protect from infection, provide thermoregulation, decompress the gut with an orogastric tube to low wall suction, monitor perfusion, and position on the side with support to prevent intestinal torsion.
• Gastrointestinal Obstruction - Hold feeds, place an orogastric tube to low wall suction, and prepare for immediate surgical intervention.
• Anorectal Malformation - Frequent assessment to ensure patency.
• Exstrophy of the Bladder - Immediately cover the exposed bladder with sterile gauze soaked in normal saline.

Most Important Intervention

• Parental and Family Support - Understand that families are in crisis and may blame themselves. Provide emotional support, understand grief and loss, and encourage family involvement in care.

Nursing Theory to Support Families

• Caring Theory - Provides a guiding framework for supporting families in crisis. Helps facilitate:
  • Knowing - Understanding the loss for the family.
  • Being With - Providing a caring presence and acceptance.
  • Doing for - Providing care for the mother and family.
  • Enabling - Providing information, guidance, and promoting autonomy.
  • Maintaining Belief - Encouraging the family's ability to cope with the loss.

This quiz covers key concepts related to post-term pregnancy and labor dystocia, including recommendations for fetal monitoring and interventions for umbilical cord compression. It also examines the 5 P's of labor which can contribute to dystocia. Enhance your understanding of labor complications and management strategies.