CHILDBIRTH AT CHILDBIRTH AT RISKRISK

Chapter 21Chapter 21

PSYCHOLOGICAL PSYCHOLOGICAL DISORDERS: BEHAVIORS DISORDERS: BEHAVIORS

IN LABORIN LABOR• Depression: decreased ability to Depression: decreased ability to

concentrate, or process information; concentrate, or process information; feeling overwhelmed and hopelessfeeling overwhelmed and hopeless

• Bipolar disorder: may be depressed or Bipolar disorder: may be depressed or hyper excitedhyper excited

• Anxiety disorder: chest pain SOB, Anxiety disorder: chest pain SOB, faintness, fearfaintness, fear

• Clinical therapy goals: decrease Clinical therapy goals: decrease anxiety, maintain orientation to reality, anxiety, maintain orientation to reality, promote optimal functioning in laborpromote optimal functioning in labor

HYPERTONIC LABOR HYPERTONIC LABOR DYSTOCIADYSTOCIA

• Characteristics: increased contraction Characteristics: increased contraction frequency and uterine resting tone; frequency and uterine resting tone; prolonged latent phaseprolonged latent phase

• Implications: prolonged labor and Implications: prolonged labor and discomfort; reduced uteroplacental discomfort; reduced uteroplacental exchange resulting inn nonreassuring exchange resulting inn nonreassuring fetal statusfetal status

• Prolonged pressure on fetal head Prolonged pressure on fetal head resulting in molding, caput succedaneum resulting in molding, caput succedaneum and cephalohematomaand cephalohematoma

Clinical therapy for Clinical therapy for Hypertonic laborHypertonic labor

• Bed rest and relaxation measuresBed rest and relaxation measures• Pharmacologic sedationPharmacologic sedation• OxytocinOxytocin• amniotomyamniotomy

HYPOTONIC LABORHYPOTONIC LABOR(fewer tan 3 contractions in (fewer tan 3 contractions in

10 min)10 min)• Usually in active phase after labor Usually in active phase after labor

already establishedalready established• Clinical therapy: oxytocin, Clinical therapy: oxytocin,

amniotomy, IV fluidsamniotomy, IV fluids• Nursing Plan:Nursing Plan:

– Assess amniotic fluid for meconiumAssess amniotic fluid for meconium– Monitor VS, FHT, I&O, minimize SVE, Monitor VS, FHT, I&O, minimize SVE,

assess for signs of infectionassess for signs of infection– Ambulate, position changes, Ambulate, position changes,

hydrotherapy relaxation exerciseshydrotherapy relaxation exercises

PRECIPITOUS LABORPRECIPITOUS LABOR(less than 3 hours)(less than 3 hours)

• Contributing factors: multiparity, large Contributing factors: multiparity, large pelvis, previous precipitous labor, small pelvis, previous precipitous labor, small fetus in a favorable position, strong fetus in a favorable position, strong contractions, uterine hyper stimulation contractions, uterine hyper stimulation from excess pitocinfrom excess pitocin

• Implications: loss of coping ability, Implications: loss of coping ability, laceration of cervix, vagina, perineum, laceration of cervix, vagina, perineum, postpartum uterine atony, hemorrhage, postpartum uterine atony, hemorrhage, fetal stress or hypoxia from intense fetal stress or hypoxia from intense uterine ctx. Cerebral trauma from rapid uterine ctx. Cerebral trauma from rapid descent, pneumothorax from rapid descent descent, pneumothorax from rapid descent

NURSING PLAN FOR NURSING PLAN FOR PRECIPITOUS LABORPRECIPITOUS LABOR

• Anticipate r/t risk factors (be prepared)Anticipate r/t risk factors (be prepared)• Frequent monitoring and assess for Frequent monitoring and assess for

accelerated labor progress (intense ctx accelerated labor progress (intense ctx with little uterine relaxation), constant with little uterine relaxation), constant nursing attendancenursing attendance

• Prepare for delivery early; keep Dr. Prepare for delivery early; keep Dr. informedinformed

• Institute supportive measures for hyper Institute supportive measures for hyper stimulation: d/c pitocin, side-lying, O2stimulation: d/c pitocin, side-lying, O2

POSTTERM (more than 42 POSTTERM (more than 42 weeks gestation)weeks gestation)

• Implications:Implications:– Probable labor inductionProbable labor induction– Risk for large babyRisk for large baby– Decreased placental perfusionDecreased placental perfusion– OligohydramniosOligohydramnios– Meconium aspirationMeconium aspiration

Nursing plan for Postterm Nursing plan for Postterm PregnancyPregnancy

• Teach fetal kick counts antenatallyTeach fetal kick counts antenatally• Ongoing FHR assessment for signs of Ongoing FHR assessment for signs of

cord compression in laborcord compression in labor• Take corrective action for cord Take corrective action for cord

compression due to oligohydramnios: compression due to oligohydramnios: position change, O2, amnioinfusionposition change, O2, amnioinfusion

• Carefully monitor labor progressCarefully monitor labor progress• Provide emotional supportProvide emotional support

FETAL MALPOSITONFETAL MALPOSITON

• Persistent occiput-posterior (OP)Persistent occiput-posterior (OP)• Fetal malpresentation:Fetal malpresentation:

– BrowBrow– FaceFace– BreechBreech– TransverseTransverse– Compound (two presenting parts)Compound (two presenting parts)

MACROSOMIA (infant MACROSOMIA (infant weight of 4000g or 8#13oz)weight of 4000g or 8#13oz)• Predisposing factors: male gender, Predisposing factors: male gender,

offspring of large parents, maternal offspring of large parents, maternal diabetes, prolonged gestation, previous diabetes, prolonged gestation, previous large infant, grand multiparity.large infant, grand multiparity.

• Implications: dysfuntional labor, soft Implications: dysfuntional labor, soft tissue laceration during birth, PP tissue laceration during birth, PP hemorrhage, CPD with subsequent hemorrhage, CPD with subsequent cesarean, meconium aspiration, cesarean, meconium aspiration, shoulder dystocia, brachial plexus shoulder dystocia, brachial plexus injury, fractured clavicle, asphyxiainjury, fractured clavicle, asphyxia

NURSING PLAN FOR NURSING PLAN FOR MACROSOMIC INFANTMACROSOMIC INFANT

• Continuous EFM; assess for fetal stress Continuous EFM; assess for fetal stress (decels)(decels)

• Assess for labor dystociaAssess for labor dystocia• Anticipate and assist with emergency Anticipate and assist with emergency

measures during birth as needed such measures during birth as needed such as McRoberts maneuver, suprapubic as McRoberts maneuver, suprapubic pressure, emergency CSpressure, emergency CS

• Anticipate uterine atony postpartumAnticipate uterine atony postpartum• Assess newborn for birth traumaAssess newborn for birth trauma

MULTIPLE GESTATION MULTIPLE GESTATION (TWINS AND MORE)(TWINS AND MORE)

• Predisposing factors: infertility Predisposing factors: infertility treatment, advanced maternal age, treatment, advanced maternal age, African American ethnicity, multiparity, African American ethnicity, multiparity, tall, overweight womentall, overweight women

• Early indicators: two gestational sacs on Early indicators: two gestational sacs on early US, fundal ht greater than early US, fundal ht greater than expected, auscultation of two or more expected, auscultation of two or more heart rates differing by more than 10 heart rates differing by more than 10 beats, elevated hCG with severe nausea beats, elevated hCG with severe nausea and vomiting, elevated alph-fetoproteinand vomiting, elevated alph-fetoprotein

Implications of multiple Implications of multiple gestationgestation

• Increased maternal discomfortIncreased maternal discomfort• PreeclampsiaPreeclampsia• Preterm laborPreterm labor• Placenta previaPlacenta previa• Abnormal fetal presentationAbnormal fetal presentation• Dysfunctional laborDysfunctional labor• Ten times greater perinatal mortalityTen times greater perinatal mortality• Increased IUGR, fetal anomalies, cerebral Increased IUGR, fetal anomalies, cerebral

palsy, and sequelae of prematuritypalsy, and sequelae of prematurity

NURSING PLAN NURSING PLAN

Prenatal: Prenatal:

educate on lifestyle modifications;educate on lifestyle modifications;

nutrition: 4000 cal daily, 135 g protein, nutrition: 4000 cal daily, 135 g protein, 40-50lb wt gn40-50lb wt gn

increased prenatal visits: weekly NST at increased prenatal visits: weekly NST at 30 wks, weekly BPP, 30 wks, weekly BPP,

educate on danger signseducate on danger signs

• Nursing Plan:Nursing Plan:– Continuous EFMContinuous EFM– 18 g IV catheter18 g IV catheter– Double setup for delivery of newborn Double setup for delivery of newborn – Alert additional staff for help with birth Alert additional staff for help with birth

and newborn careand newborn care– Be prepared for CSBe prepared for CS

FETAL DISTRESSFETAL DISTRESS

• Common causes: cord compression, Common causes: cord compression, uteroplacental insufficiency, uteroplacental insufficiency, placental abnormalities, preexisting placental abnormalities, preexisting maternal or fetal diseasematernal or fetal disease

• Fetal implications: chronic hypoxia, Fetal implications: chronic hypoxia, permanent organ damage, potential permanent organ damage, potential emergent CSemergent CS

• Common initial signs of fetal stress: Common initial signs of fetal stress: meconium-stained amniotic fluid, persistent meconium-stained amniotic fluid, persistent late decels, persistent severe variable decelslate decels, persistent severe variable decels

• Institute Intrauterine Resuscitation Institute Intrauterine Resuscitation measures:measures:– Correct maternal hypotension and enhance Correct maternal hypotension and enhance

uteroplacental blood flowuteroplacental blood flow• Change position that improves FHR, Change position that improves FHR, • Increase rate of IVIncrease rate of IV• O2 via face maskO2 via face mask• Decrease uterine activity: stop pitocin, adm tocolyticDecrease uterine activity: stop pitocin, adm tocolytic• Perform vaginal exam (prolapsed cord?)Perform vaginal exam (prolapsed cord?)

ABRUPTIO PLACENTAE ABRUPTIO PLACENTAE (premature separation of (premature separation of

placenta)placenta)• Contributing factors: hydramnios, Contributing factors: hydramnios,

twins, smoking, street drugs, traumatwins, smoking, street drugs, trauma• Significant symptoms: pain, uterine Significant symptoms: pain, uterine

irritability, and a firm, hard abdomenirritability, and a firm, hard abdomen• Types: Types:

– MarginalMarginal– CentralCentral– CompleteComplete

• Maternal implications: intrapartum Maternal implications: intrapartum hemorrhage, DIC, ruptured uterus, hemorrhage, DIC, ruptured uterus, fatal hemorrhagic shockfatal hemorrhagic shock

• Fetal-neonatal implications: Fetal-neonatal implications: sequelae of prematurity, hypoxia, sequelae of prematurity, hypoxia, anemia, brain damage, fetal demiseanemia, brain damage, fetal demise

Nursing planNursing plan

• Maintain two large bore IV sitesMaintain two large bore IV sites• Monitor frequentlyMonitor frequently• Monitor for signs of DICMonitor for signs of DIC• Monitor I&O hourlyMonitor I&O hourly• Measure abdominal girth hourly as Measure abdominal girth hourly as

well as vital signs q 15 minuteswell as vital signs q 15 minutes• Prepare for CS and neonatal Prepare for CS and neonatal

resuscitationresuscitation

Placenta Previa (placenta Placenta Previa (placenta implanted in lower uterine implanted in lower uterine

segmentsegment• Categories : total, partial, marginal, Categories : total, partial, marginal,

low-lyinglow-lying• Most accurate diagnostic sign is Most accurate diagnostic sign is

painless, bright-red vaginal painless, bright-red vaginal bleeding.bleeding.

• Implications: changes in FHR, Implications: changes in FHR, meconium staining, fetal hypoxia, meconium staining, fetal hypoxia, cesarean birth, neonatal anemiacesarean birth, neonatal anemia

NURSING PLANNURSING PLAN

• No vaginal exams!No vaginal exams!• Assess blood loss, pain, uterine contractionsAssess blood loss, pain, uterine contractions• Continuous external monitoringContinuous external monitoring• Monitor VS and I&O oftenMonitor VS and I&O often• Maintain IV accessMaintain IV access• Provide emotional supportProvide emotional support• Promote neonatal adaptation: resuscitate as Promote neonatal adaptation: resuscitate as

needed, evaluate H/H, administer oxygen needed, evaluate H/H, administer oxygen and blood as neededand blood as needed

UMBILICAL CORD UMBILICAL CORD PROLAPSE (cord precedes PROLAPSE (cord precedes the fetal presenting part the fetal presenting part

and gets trapped)and gets trapped)• Implications: extreme maternal emotional Implications: extreme maternal emotional stress, CS, hypoxia, brain damage, fetal stress, CS, hypoxia, brain damage, fetal deathdeath

• Nursing Plan: perform a vaginal exam to Nursing Plan: perform a vaginal exam to establish engagement or rule out establish engagement or rule out prolapse,prolapse,

• Maintain hand in vagina to relieve cord Maintain hand in vagina to relieve cord compression, assist to knee-chest compression, assist to knee-chest position, prepare for stat CS. position, prepare for stat CS.

Amniotic Fluid EmbolismAmniotic Fluid Embolism

• S&S: dyspnea, cyanosis, frothy S&S: dyspnea, cyanosis, frothy sputum, chest pain, tachycardia, sputum, chest pain, tachycardia, hypotension, mental confusion, hypotension, mental confusion, massive hemorrhagemassive hemorrhage

• Nursing Plan: summon emergency Nursing Plan: summon emergency team, O2, large bore IV, CPR as team, O2, large bore IV, CPR as needed, prepare for CS birth, needed, prepare for CS birth, administer blood administer blood

HYDRAMNIOS HYDRAMNIOS

• Greater than 2000ml of amniotic fluidGreater than 2000ml of amniotic fluid• Cause unknown but major fetal Cause unknown but major fetal

anomalies are present in 20%anomalies are present in 20%• Implications for Mother: shortness of Implications for Mother: shortness of

breath, edema, uterine dysfunction, breath, edema, uterine dysfunction, abruptio placenta, PP hemorrhageabruptio placenta, PP hemorrhage

• Implications for fetus: malformations, Implications for fetus: malformations, preterm birth, increases mortality preterm birth, increases mortality rate, prolapsed cord, malpresentationrate, prolapsed cord, malpresentation

OLIGOHYDRAMNIOSOLIGOHYDRAMNIOS

• Amniotic fluid reduced or concentrated to less Amniotic fluid reduced or concentrated to less than 50% of normal or less than 500 ml at termthan 50% of normal or less than 500 ml at term

• Found in postmaturity , and associated Found in postmaturity , and associated primarily with fetal renal defects or placental primarily with fetal renal defects or placental insufficiencyinsufficiency

• Implications: dysfunctional labor with slow Implications: dysfunctional labor with slow progressprogress

• Umbilical cord compression, head compressionUmbilical cord compression, head compression• May need amnioinfusion during laborMay need amnioinfusion during labor

CEPHALOPELVIC CEPHALOPELVIC DISPROPORTION (CPD)DISPROPORTION (CPD)

• A contracture or narrow diameter in A contracture or narrow diameter in birth passage especially if fetus is larger birth passage especially if fetus is larger than the maternal pelvic diameters.than the maternal pelvic diameters.

• Implications: Maternal: prolonged labor, Implications: Maternal: prolonged labor, arrest of descent, uterine rupture, arrest of descent, uterine rupture, forceps-assisted birth with traumaforceps-assisted birth with trauma

• Implications: Fetal: cord prolapse, Implications: Fetal: cord prolapse, excessive molding of head, birth trauma excessive molding of head, birth trauma to skull and CNSto skull and CNS

Nursing Plan for CPDNursing Plan for CPD

• Assess cervical change and fetal Assess cervical change and fetal descent frequentlydescent frequently

• Continuously monitor FHTContinuously monitor FHT• Be alert for signs of fetal stressBe alert for signs of fetal stress• Assist with optimal positioning Assist with optimal positioning

during labor such as squatting, during labor such as squatting, hands and knees hands and knees

Complications of 3Complications of 3rdrd and 4 and 4thth stages of Laborstages of Labor

• Retained Placenta: beyond 30 minutes Retained Placenta: beyond 30 minutes after birthafter birth

• Lacerations: first, second, third (extends Lacerations: first, second, third (extends through the perineal body and involves through the perineal body and involves the anal sphincter and fourth (extends the anal sphincter and fourth (extends through the rectal mucosa to the lumen through the rectal mucosa to the lumen of the rectum.of the rectum.

• Placenta accreta: the chorionic villi Placenta accreta: the chorionic villi attach directly to the myometrium of the attach directly to the myometrium of the uterus uterus

Fetal DeathFetal Death

REVIEWREVIEW

• Dystocia/hypotonic – difficult, often Dystocia/hypotonic – difficult, often prolonged labor caused by dysfunctional prolonged labor caused by dysfunctional or uncoordinated uterine activityor uncoordinated uterine activity– Irregular in timing, strength or both and Irregular in timing, strength or both and

arrest cervical changearrest cervical change– Pharmocologic sedation will frequently stop Pharmocologic sedation will frequently stop

these contractionsthese contractions– If rest doesn’t improve the pattern, labor If rest doesn’t improve the pattern, labor

stimulation with pitocin may be used if CPD stimulation with pitocin may be used if CPD ruled outruled out

• Precipitous birth is not the same as Precipitous birth is not the same as precipitous labor. Precipitous labor precipitous labor. Precipitous labor is simply a rapid labor followed by is simply a rapid labor followed by anticipated birth., Precipitous birth anticipated birth., Precipitous birth is unexpected, sudden and often is unexpected, sudden and often unattended. unattended.

• There are both maternal and fetal There are both maternal and fetal risks with precipitous laborrisks with precipitous labor

• Implications of postterm primarily stem Implications of postterm primarily stem from decreasing placental function and from decreasing placental function and concerns abut fetal size and well-beingconcerns abut fetal size and well-being

• Meconium is more common in postterm Meconium is more common in postterm pregnancies, possibly due to fetal pregnancies, possibly due to fetal maturity, or stress related to suboptimal maturity, or stress related to suboptimal placental functioningplacental functioning

• Careful assessment of labor progress is Careful assessment of labor progress is warranted due to the risk of CPD from warranted due to the risk of CPD from macrosomiamacrosomia

MALPOSITIONMALPOSITION

• Occiput posterior is the most Occiput posterior is the most common fetal malpositioncommon fetal malposition

• During labor, 90 to 95% of OP During labor, 90 to 95% of OP fetuses rotate to OA positionfetuses rotate to OA position

• Maternal position such as hands and Maternal position such as hands and knees may facilitate fetal rotation knees may facilitate fetal rotation and relieve back painand relieve back pain

MalpresentationsMalpresentations

• Brow, face, breech shoulder and Brow, face, breech shoulder and compoundcompound

• Many brow presentations convert to Many brow presentations convert to occipital or face with fetal descentoccipital or face with fetal descent

• Reassure the couple that the edema Reassure the couple that the edema and bruising are temporary and will and bruising are temporary and will be markedly improved in 3-4 days, be markedly improved in 3-4 days, though complete resolution may take though complete resolution may take several weeks.several weeks.

• The nurse is frequently the first to The nurse is frequently the first to recognize breech presentation through recognize breech presentation through Leopold’s maneuvers and vaginal exam.Leopold’s maneuvers and vaginal exam.

• Footling breech, nurse must be alert Footling breech, nurse must be alert for prolapsed cord. The danger is for prolapsed cord. The danger is greater if there is a small fetus and greater if there is a small fetus and membranes are rupturedmembranes are ruptured

• If transverse lie persists at term, If transverse lie persists at term, external cephalic version may be usefulexternal cephalic version may be useful

MacrosomiaMacrosomia

• Primary risks are CPD and shoulder Primary risks are CPD and shoulder dystociadystocia

• Dysfunctional labor or lack of fetal Dysfunctional labor or lack of fetal descent could indicate CPDdescent could indicate CPD

• Birth trauma associated with this are:Birth trauma associated with this are:– Erb’s palsyErb’s palsy– Fractured clavicleFractured clavicle– cephalohematomacephalohematoma

More than one fetusMore than one fetus

• Clinical monitoring usually begins in Clinical monitoring usually begins in 33rdrd trimester and continues until trimester and continues until nonreassuring findings are obtained nonreassuring findings are obtained or birth occursor birth occurs

Abruptio PlacentaeAbruptio Placentae

• Separation of normally implanted Separation of normally implanted placentaplacenta

• Occurs more frequently in pregnancies Occurs more frequently in pregnancies with hypertension and cocaine abuse. with hypertension and cocaine abuse. Also smoking and alcohol ingestion are Also smoking and alcohol ingestion are contributing factorscontributing factors

• Clotting disorders (DIC) result when Clotting disorders (DIC) result when uterine wall damage and retroplacental uterine wall damage and retroplacental clotting from central separation trigger clotting from central separation trigger release of a large amount of release of a large amount of thromboplastin into maternal circulationthromboplastin into maternal circulation

• If separation is mild and pregnancy If separation is mild and pregnancy near term, labor induction may be near term, labor induction may be feasiblefeasible

• Signs are painful, board like Signs are painful, board like distended abdomen and uterine distended abdomen and uterine irritabilityirritability

Placenta PreviaPlacenta Previa

• Signs are painless bleeding. Abdomen is Signs are painless bleeding. Abdomen is softsoft

• Management based on gestational age at Management based on gestational age at first bleeding episode and the amount of first bleeding episode and the amount of bleedingbleeding

• No vaginal exams should be done by nurseNo vaginal exams should be done by nurse• Preterm can usually be managed with bed Preterm can usually be managed with bed

rest with bathroom privileges only as long rest with bathroom privileges only as long as there is no bleeding, pain and uterine as there is no bleeding, pain and uterine contractions until fetus is mature.contractions until fetus is mature.

Umbilical cord ProlapseUmbilical cord Prolapse

• Compresses the blood vessels to and Compresses the blood vessels to and from the fetus. Labor ctx further from the fetus. Labor ctx further compress the cordcompress the cord

• A drop in fetal heart rate accompanied A drop in fetal heart rate accompanied by variable decelerations is consistent by variable decelerations is consistent with prolapse cord. And a vaginal with prolapse cord. And a vaginal exam is the best way to confirm. exam is the best way to confirm.

• The number one priority is to relieve The number one priority is to relieve compression to allow blood flow to compression to allow blood flow to reach fetus. A c-section is imminent. reach fetus. A c-section is imminent.

PolyhydramniosPolyhydramnios

• Occurs in 10 to 20% of pregnant diabeticsOccurs in 10 to 20% of pregnant diabetics• Major fetal anomalies are present in 20% of Major fetal anomalies are present in 20% of

casescases• Uterine over distention may result in labor Uterine over distention may result in labor • dysfunction and postpartum hemorrhagedysfunction and postpartum hemorrhage• Rupture of membranes increases risk of cord Rupture of membranes increases risk of cord

prolapseprolapse• An abnormally taut abdomen with difficulty An abnormally taut abdomen with difficulty

palpating the fetus may be suspicious for palpating the fetus may be suspicious for hydramnioshydramnios