Preterm Labor and Birthing Process

Lesson 8.1 Objectives

• Define each key word listed.
• Discuss each obstetric procedure discussed in the chapter.
• Illustrate the nurse's role in each obstetric procedure.
• Analyze the nurse's role in a cesarean birth.

Obstetric Procedures

• Amnioinfusion is one type of obstetric procedure.
• Version is another type of obstetric procedure.
• Induction is another type of obstetric procedure.
• Augmentation is another type of obstetric procedure.

Bishop Scoring System

• The Bishop scoring system measures how ready the cervix is for induction.
• A higher score on the Bishop scoring system indicates a more successful induction.

Indications for Labor Induction

• Maternal conditions, such as gestational hypertension, preeclampsia, and eclampsia, can be indications for labor induction.
• Ruptured membranes without spontaneous onset of labor is an indication for labor induction.
• Labor induction is indicated when there is an infection within the uterus, such as chorioamnionitis.
• Medical problems in the patient that worsen during pregnancy, such as diabetes and ESRD, can be indications for labor induction.
• Fetal problems, such as slowed growth, prolonged pregnancy, or incompatibility between fetal and maternal blood types, can be indications for labor induction.
• Placental insufficiency and fetal death are also indications for labor induction.

Contraindications to Induction

• Placenta previa, umbilical cord prolapse, and abnormal fetal presentation are contraindications for induction.
• High station of the fetus, active herpes infection in the birth canal, abnormal size or structure of the patient's pelvis, and previous classical cesarean incision are also contraindications.

Augmentation

• Labor begins spontaneously.
• Labor has fizzled out.
• Maternal or fetal health concern.
• Natural, pharmacological and mechanical interventions are available.

Pharmacologic Methods to Stimulate Contractions

• Cervical ripening with prostaglandin E2 Cervidil (Dinoprostone) involves intravaginal insertion and sustained release, usually overnight.
• Prostaglandin E1 Cytotec (Misoprostol) involves intravaginal insertion or PO and is more effective at producing vaginal delivery within 24 hours.
• Pitocin induction and the augmentation of labor involve IV administration of titrated Pitocin to stimulate uterine contractions.
• A primary risk of Pitocin is Uterine TACHYSYSTOLE or TETANY.

Preparing the Patient for Labor Augmentation

• Explain procedure to patient.
• Obtain baseline VS and fetal heart rate.
• Ensure patent IV line is placed.
• Ensure patient remains 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

• Methods for dilating the cervix include stripping amniotic membranes, hydroscopic dilators, and transcervical balloon dilators.

Amniotomy

• Amniotomy is the artificial rupture of membranes.
• Amniotomy is done to stimulate or enhance contractions.
• Amniotomy commits the patient to delivery.
• Amniotomy stimulates prostaglandin secretion.
• Complications of amniotomy can include prolapse of the umbilical cord, infection, and abruptio placentae.

Complications Associated with Amniotomy

• Prolapsed umbilical cord.
• Infection.
• Abruptio placentae.

Nonpharmacologic Methods to Stimulate Contractions

• Walking stimulates contractions (if true labor)
• Walking eases pressure of the fetus on the patient's back.
• Walking adds gravity to the downward force of contraction.
• Semen deposit on cervix is a nonpharmacologic method.
• Nipple stimulation via suckling causes the pituitary gland to secrete natural oxytocin.

Obstetric Version

• A method used to change fetal presentation.
• Two methods include external, usually performed at 37 weeks' gestation but before onset of labor, and internal, emergent, during labor.
• Risks and contraindications include disproportion between the patient's pelvis and fetal size, abnormal uterine or pelvic size or shape, abnormal placental placement, and previous cesarean birth with vertical uterine incision.
• Other risks involve active herpes virus infection, inadequate amniotic fluid, poor placental function, multifetal gestation, or fetus can become entangled in umbilical cord.

Episiotomy

• An episiotomy is controlled surgical enlargement of the vaginal opening during birth.
• Indications for episiotomy include better control over where and how much the vaginal opening is enlarged, and an opening with a clean edge rather than the ragged opening of a tear. -Perineal massage and stretching exercises before labor may be an alternative to an episiotomy.

Perineal Lacerations

• Perineal lacerations consist of uncontrolled tearing of perineal tissue.
• First degree laceration is superficial vaginal mucosa or perineal skin.
• Second degree lacerations involve vaginal mucosa, perineal skin, and deeper tissues of the perineum.
• Third degree lacerations entail the same as second degree, plus involves anal sphincter.
• Fourth-degree lacerations extend through the anal sphincter into the rectal mucosa.

Forceps Extraction

• Forceps extraction provides traction and rotation of the fetal head when the patient's pushing efforts are insufficient to accomplish a safe delivery.
• Forceps extraction is used at the end of the second stage of labor in vaginal delivery.
• Forceps may also help the physician extract the fetal head through the incision during a cesarean birth.

Vacuum Extraction Birth

• Vacuum extraction uses suction applied to the fetal head so the physician can assist the mother's expulsive efforts.
• A vacuum is used only with occiput presentation and the end of the second stage of labor.

Risks of Forceps or Vacuum Extraction

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

Cesarean Birth: Indications

• Indications include abnormal labor, inability of the fetus to pass through the maternal pelvis, maternal conditions such as GH or DM, active maternal herpes virus, and previous surgery on the uterus.
• Other considerations might include a fetal compromise, or placenta previa or abruptio placentae.

Preparation for Cesarean Birth

• Clinical lab studies to identify anemia and blood-clotting abnormalities, including CBC, coagulation studies, and blood type & cross.
• Baseline vital signs, including fetal heart rate.
• Position patient for comfort, IV line, and Foley catheter inserted.

Types of Incisions - Skin

• Vertical allows more room for a large fetus.
• Transverse (a.k.a. Pfannenstiel).

Types of Incisions - Uterine

• Low transverse is not likely to rupture during another birth, VBAC possible with this type.
• Low vertical has minimal blood loss, and more likely to rupture during another birth,.
• Classic is rarely used; creates more blood loss; most likely to rupture during another pregnancy.

Nursing Care in the Recovery Room

• Monitor vital signs to identify hemorrhage or shock.
• Monitor IV site and rate of solution flow.
• Fundus for firmness, height, and midline position.
• Dressing for drainage.
• Lochia for quantity, color, and presence of clots.
• Urine output from the indwelling catheter.

Lesson 8.2 Objectives

• Describe factors that contribute to an abnormal labor.
• Explain each intrapartum complication discussed in this chapter.

Abnormal Labor

• Abnormal labor is called dysfunctional labor.
• Abnormal labor does not progress normally.
• Abnormal labor is also called dystocia and means difficult labor.

Problems with the Powers of Labor

• Hypertonic contractions.
• Hypotonic contractions.

Ineffective Maternal Pushing

• A 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 to push.
• An exhausted woman may be unable to gather enough energy to push.

Problems with the Fetus

• The passenger, or the fetus, might cause the labor's progression to be dysfunctional.
• These problems include size, presentation, or positioning.
• Other factors might include multifetal pregnancies and birth defects.

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 the patient 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 contributes 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 as breech unless a version is done.

Problems with the Pelvis and Soft Tissues

• Bony pelvis can be a problem, but Gynecoid pelvis more likely.
• Soft tissue obstructions, most common is a full bladder.

The Psyche

Most common factors that can prolong labor

• Lack of analgesic control of 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; can impede fetal descent.
• Increases perception of pain.

Abnormal Duration of Labor

• Friedman curve.
• Often used to graph the progress of cervical dilation and fetal descent.
• 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, greater anxiety and fear.

Precipitate Birth

• A type of birth that is completed in less than 3 hours from labor onset.
• Labor begins abruptly and intensifies quickly.
• Contractions may be frequent and intense.
• May have uterine rupture, cervical lacerations, or hematoma. Fetal oxygenation may be compromised.
• Birth injury may occur from rapid passage through the birth canal.
• Injuries can include intracranial hemorrhage and 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.
• Diagnosis confirmed by Nitrazine paper test, involves looking for a "ferning" pattern from vaginal fluid placed on a slide and viewed under the microscope.

Patient Teaching for a Woman with Infection or in Preterm Labor

• Report a temperature that is above 38°C (100.4°F).
• Avoid sexual intercourse or insertion of anything into vagina.
• Avoid orgasms.
• Avoid 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: Some Risk Factors

• Exposure to DES, and being Underweight
• Chronic illness, and Dehydration
• Preeclampsia
• Previous preterm labor or birth, and previous pregnancy losses
• Substance abuse, and Chronic stress.

Preterm Labor: Some Risk Factors

• Infection.
• Anemia.
• Preterm PROM.
• Inadequate prenatal care.
• Poor nutrition.
• Low education level.
• Poverty.
• Smoking.
• Multifetal presentation.

Signs of Impending Preterm Labor

• A Shortened cervix on ultrasound at 20 weeks may be predictive of preterm labor.
• Diagnosis is based on cervical effacement and dilation of more than 2 cm.
• A fibronectin test.
• The presence of fibronectin in vaginal secretions between 22 and 24 weeks' gestation is predictive of preterm labor and fetal membranes and leaks into vaginal secretions if uterine activity, infection, or cervical effacement occurs.

Maternal Symptoms of Preterm Labor

• Contractions that may be either uncomfortable or painless.
• Feeling that the fetus is "balling up" frequently.
• Menstrual-like cramps.
• 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 (1 of 2)

• 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).
• Prostaglandin synthesis inhibitors.

Tocolytic Therapy (2 of 2)

• Contraindications include preeclampsia.
• Placenta previa.
• Abruptio placentae.
• Gestational age over 37 weeks.
• Chorioamnionitis.
• Fetal demise.

Stopping Preterm Labor

• Initial measures to stop preterm labor include identifying and treating infection, activity restriction, and hydration.
• If successful, patient may be sent home with strict return instructions and activity restrictions.

Stopping Preterm Labor

• Secondary measures to stop preterm labor.
• Drug therapy - Oral or IV as medication:
  • Betamimetics
  • Calcium channel blockers
  • magnesium sulfate
  • Oxytocin receptor blockers
  • Prostaglandin inhibitors
  • Nitrates and others

Stopping Preterm Labor

• If it appears preterm birth is inevitable.
• Amniocentesis to assess fetal maturity.
• Steroids increase fetal lung maturity like betamethasone
• Thyroid-releasing hormone also enhances lung maturity in fetuses younger than 28 weeks.

Antenatal Corticosteroids

• Antenatal steroids, compared with placebo or no treatment, given to pregnant women at risk of giving birth before 37 weeks.
• A single course of antenatal steroids reduces the risk of serious respiratory illness and death in neonates in low-middle- and high- income countries.

Prolonged Pregnancy

• Lasts longer than 41 weeks.
• Placenta ages.
• Delivers oxygen and nutrients to the fetus less efficiently.
• Fetus may lose weight.
• Fetal skin may peel.
• Fetus continues to grow.
• Meconium may be expelled.
• Low blood glucose levels in the fetus.

Tests Used to Confirm the Diagnosis of Prolonged Pregnancy

• Tests used to Confirm the Diagnosis of Prolonged Pregnancy are indicated in any pregnancy that lasts longer than 40 weeks.
• Include nonstress tests (NST), amniotic fluid index (AFI), biophysical profile (BPP), and 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

• Prolapsed umbilical cord can be complete, palpated, or occult.
• Placenta accreta.

Emergencies During Childbirth

• Involve uterine rupture, which can be complete, incomplete, or dehiscence.
• Primary risk factor is VBAC.
• Uterine rupture is painful, involves sharp pain in abdomen & chest, change in belly shape, loss of contractions.

Amniotic Fluid Embolism

• Occurs when amniotic fluid, with its particles such as vernix, fetal hair, and sometimes meconium, enters the woman's circulation and typically obstructs small blood vessels in her lungs.
• Characterized by abrupt onset of hypotension, respiratory distress, and coagulation abnormalities from thromboplastin in amniotic fluid.

Vocabulary

Artificial rupture of membranes (AROM): The intentional puncture of the amniotic sac and release of amniotic fluid to induce or augmenting labor Augmentation of labor: Enhancement of labor after it has begun; stimulation of contractions after they have begun naturally. Bishop score: Scoring system that uses cervical dilation, position, effacement, station & consistency to determine if labor can be safely induced. Cephalopelvic disproportion: A condition in which the fetus cannot pass through maternal pelvis. Chignon: Newborn scalp edema created by a vacuum extractor. Chorioamnionitis: An ascending infection in the lower genitourinary tract and migrating to amniotic cavity. Also called "intrauterine infection during pregnancy." Dysfunctional labor: Ineffective labor pattern that won't effectively deliver infant. Shoulder dystocia: An obstetric emergency where the anterior fetal shoulder becomes stuck on maternal symphysis, delaying birth of baby's body. Hydramnios: Polyhydramnios, or a condition in which there is too much amniotic fluid around the fetus. Induction of labor: To cause labor to begin. Macrosomia: Abnormally large infant, or neonatal birth weight above 90th percentile. Oligohydramnios: A condition in which there is not enough amniotic fluid around the fetus. Oxytocis: Drugs that intensify uterine contractions to hasten birth or control postpartum hemorrhage. Tocolytics: Drugs that reduce uterine contractions, used to delay labor onset and prevent pre-term delivery. Spontaneous rupture of membranes: SROM, rupture of fetal membranes occurring on its own Version; Turning the position of fetus in uterus before birth; can be spontaneous or manually induced Tachysystole: Uterine contraction frequency of more than once every 2 minutes or five or more contractions within 10 minutes with duration longer than 90 seconds or a resting interval between contractions less than 60 seconds.

This lesson covers preterm labor, its complications, and the birthing process. Topics include the impact of pelvic muscle tension, diagnosis of PROM, fetal monitoring, and risk factors for preterm labor, such as smoking.