maternal nursing care- chpt 14 caring for women with complications during labor

427

chapterchapterCaring for the Woman Experiencing Complications

During Labor and Birth1414

And when our baby stirs and struggles to be born it compels humility, what we began is now its own.

Anne Ridler

LEARNING TARGETS At the completion of this chapter, the student will be able to:

Differentiate critical factors associated with nursing care of women experiencing dysfunctional labor patterns.

Discuss pharmacological and nonpharmacological interventions used for the induction and augmentation of labor.

Discuss collaborative care of the woman experiencing an induction of labor.

Compare and contrast methods of instrumentation assistance of birth.

Describe the management of selected maternal complications during the intrapartal period.

Discuss how fetal malpresentation and malposition affect labor and birth.

Compare and contrast the intrapartal management for placenta previa and abruptio placentae.

Describe emergency nursing care for various uterine, placental, umbilical, and amniotic complications during labor and birth.

Plan appropriate nursing care for a family experiencing a fetal loss.

Discuss maternal and fetal factors associated with cesarean birth.

Describe the controversies associated with vaginal birth after cesarean birth.

moving toward evidence-based practice Maternal placental syndrome as it relates to cardiovascular healthRay, J.G., Vermeulen, M.J., Schull, M.J., & Redelmeier, D.A. (2005). Cardiovascular health after maternal placental syndromes (CHAMPS): Population-based retrospective cohort study. The Lancet, 366, 17971803.

Research indicates that the presence of maternal placental syn-dromes, which include hypertensive disorders of pregnancy and abruption or infarction of the placenta, probably originate from diseased placental vessels. These conditions occur more often in women with metabolic risk factors for cardiovascular disease such as obesity, hypertension, diabetes, and hyperlipidemia. The purpose of this study was to assess for the risk of premature vascular disease in women who experienced maternal placental syndrome during pregnancy.

The population-based retrospective cohort study included 1.03 million women who had no evidence of cardiovascular dis-ease before their fi rst documented delivery. The sample, obtained

through multiple databases, consisted of women admitted to the hospital for the fi rst obstetrical delivery of a live or stillborn infant after 20 weeks of gestation. Women younger than age 14, older than age 50, and those with a preexisting diagnosis of cardiovas-cular disease in the 24 months preceding the birth were excluded.

Maternal placental syndrome included preeclampsia, gesta-tional hypertension, placental abruption, and placental infarction. A history of hospitalization for cardiovascular, coronary artery, or peripheral artery disease a minimum of 90 days after the delivery discharge date was identifi ed as the point for determining the composite for the development of cardiovascular disease.

(continued)

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428 unit four The Birth Experience

moving toward evidence-based practice (continued)

Data analysis revealed the following fi ndings: The mean age of the participants was 28.2 years at the

time of the infants birth. Maternal placental syndrome was diagnosed in 75,380

(7%) of the women. The incidence of cardiovascular disease was 500 per one

million person-years in women with a placental syn-drome, as compared to 200 per one million-person years in those who did not have a placental syndrome.

The risk of cardiovascular disease was higher with the combined presence of maternal placental syndrome and either poor fetal growth or intrauterine fetal death.

Of those diagnosed with the maternal placental syn-drome, risk factors were more commonly present before delivery than in those participants who were not diag-nosed with the maternal placental syndrome.

The median period for follow-up was 8.7 years. The mean age of the participants at the time of the fi rst cardiovas-cular event was 38.3 years; the maximum age of the participants was 60.2 years.

The risk of cardiovascular disease increased with the number of risk factors present.

The risk of premature cardiovascular disease is higher in women who have experienced maternal placental syndrome, especially in the presence of fetal compli-cations.

1. What might be considered as limitations to this study? 2. How is this information useful to clinical nursing practice?

See Suggested Responses for Moving Toward Evidence-Based Practice on the Electronic Study Guide or DavisPlus.

Introduction

The nurse who cares for women and their families experi-encing complications during labor and birth is responsible for creating a supportive environment that provides com-plex nursing care. Under normal circumstances labor and birth places stress on the family unit and when problems are superimposed during this time frame, another layer of complexity is added. The woman often needs to respond rapidly to changing health conditions for which she might not be prepared. The nurse has to be proactive and reas-suring in support of the woman and her family unit. It is critical to empower the woman and encourage her to take control as much as possible. The nurse acts as her advocate in collaborative care when the woman is unable to have her voice.

Complications arise from a variety of factors. Women experience problems with uterine dysfunction often referred to as the powers of labor. The presentation and position of the fetus is integral to a positive labor out-come. When the fetus is not in a favorable lie, the labor process may lengthened, require instrumentation assis-tance, or necessitate an operative birth. Multiple fetuses are more prone to these issues because of their locations within the uterus. Placenta obstruction or an inadequate bony pelvis may hinder fetal progress through the birth canal and require more extensive medical intervention. Medical emergencies and complications from maternal disease also place the patient at increased risk for a com-plicated and intervention-driven labor and birth.

Cesarean or operative birth is one of the outcomes associated with a complicated labor. In the United States, the cesarean birth rate has steadily increased. Controversy surrounds this statistic while at the same time more women are requesting an elective cesarean birth. The nurse working in perinatal care has to be concerned with ethical issues and be prepared to foster evidence-based research studies to examine the multiple factors involved with cesarean deliveries.

Perinatal loss necessitates a collaborative response from all professionals involved in the care of the patient. Nurses can lead others in providing support. Spiritual, emotional, psychological, and physical needs are important consider-ations that need to be met during this time. Although this situation cannot be normalized, the nurse can encourage the woman to hold her infant, give her a baby picture, and provide a memory book to acknowledge the existence of the child.

The nurse serves in many capacities when managing the care of patients experiencing a complicated labor and birth. Use of the nursing process combined with a strong theoretical background provides a foundation for the critical decision making that exists in the clinical unit. Nursing diagnoses specifi c to the woman experiencing a complica-tion during the intrapartal period refer to specifi c problems and often relate to the broad concepts of fear, anxiety, cop-ing, and fatigue. Examples of possible nursing diagnoses are presented in Box 14-1. The nurse has the unique opportu-nity to empower the woman and assist her in taking control as much as possible in these diffi cult situations. Since patients are unique in their responses, it is incumbent upon the nurse to be sensitive to all individuals and be culturally competent. Finally, the nurse must constantly examine practice and promote research initiatives that give evidence to optimal outcomes in complex perinatal care.

Optimizing Outcomes Helping to meet Healthy People 2010 national goals

Nurses who work with birthing mothers can be instrumen-tal in helping the nation to meet Healthy People 2010 goals that address intrapartal complications:

Reduce the maternal mortality rate to no more than 3.3 per 100,000 live births from a baseline of 7.1 per 100,000.

Reduce cesarean births among low-risk women to no more than 15 per 100 deliveries from a baseline of 18 per 100 by carefully monitoring laboring women to


chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 429

identify early signs of potentially life-threatening events (i.e., placental abruption, uterine rupture) and by assist-ing women with fetal malpresentations amenable to rotation with positional changes to help reduce the number of cesarean births.

Dystocia

Dystocia, defi ned as a long, diffi cult or abnormal labor, is a term used to identify poor labor progression. Dystocia may arise from any of the three major components of the labor processthe powers (uterine contractions), the passenger (fetus), or the passageway (maternal pelvis). In addition, various medical interventions used during labor and birth may create problems that complicate the birth process.

Dystocia may be related to maternal positioning during labor, as well as fetal malpresentation, anomalies, macro-somia and multiple gestation. Also, maternal psychological responses to the labor, based on past experiences, cultural infl uences, and the womans present level of support may play a role in the normal progress of labor.

Nursing Insight Recognizing indicators of dystocia

Nurses should suspect dystocia when there is a lack of progress in the rate of cervical dilation; fetal descent and expulsion; or an alteration in the pattern of normal uterine contractions.

DYSFUNCTIONAL LABOR PATTERNSDysfunctional labor patterns are deviations from the nor-mal pattern of labor as illustrated by a labor curve assess-ment tool. (See Chapter 12.) Labor alterations occur more

frequently during the fi rst stage of labor (cervical dilation and effacement) than during the second stage (maternal expulsive efforts). Nulliparous women have a higher inci-dence of abnormalities than do multiparous women. Dys-functional labor is the fourth most common complication of labor and birth, and several factors may increase a womans risk for dystocia (Box 14-2). There are two gen-eral types of labor dysfunction: hypertonic and hypotonic (Fig. 14-1). These contraction patterns are classifi ed according to when they occur in labor and the nature of the uterine contractions.

HYPERTONIC LABORHypertonic labor contractions are strong and often pain-ful but are ineffective in producing cervical effacement and dilation. An increase in maternal catecholamine release (i.e., epinephrine, norepinephrine) can result in poor uterine contractility (Cunningham et al., 2005). Uterine pacemakers (the energy source of contractions located in the uterine wall) do not initiate a good myometrial response needed for progressive cervical change. Instead, irregular spasmodic episodes occur that do not result in effective contractions or assist in bringing the fetus into a more favorable downward position (Gilbert, 2006).

Maternal anxiety plays a major role in hypertonic labor. Anxiety is known to produce high levels of cate-cholamines. Many factors contribute to a womans fear related to labor and birth:

Primiparous labor Loss of control Sexual abuse Lack of support Cultural differences Fear of pain

An occiputposterior malposition of the fetus, which occurs in approximately 15% of labors, also leads to hypertonic labor contractions. In approximately one half of all cases of hypertonic labor patterns, however, there is no apparent cause (Gilbert, 2006).

Although the management of hypertonic labor contrac-tions varies, in general, the emphasis is on establishing a more effective labor pattern. Rest, hydration, and sedation reduce the irritability of the uterus and help to diminish the ineffective contractions. Medications that may be prescribed to induce therapeutic rest include meperidine (Demerol),

Box 14-1 Possible Nursing Diagnoses for the Woman Experiencing Complications During Labor and Birth

Fear related to unknown high risk condition of labor Anxiety related to loss of control during labor Coping, Ineffective, related to inadequate opportunity to prepare for

high risk labor Fatigue related to increased physical exertion during a long labor Powerlessness related to lack of control over decisions in a complicated

birth Defi cient Knowledge related to unknown high risk condition Communication, Verbal Impaired, related to cultural differences Risk for Spiritual Distress related to emotional response to high risk

labor and birth Risk for Ineffective Tissue Perfusion related to excessive loss of blood Risk for Injury related to damage of tissue during a complicated birth Pain, Acute, related to tissue damage Fluid Volume, Defi cit, related to decreased urinary output Fluid Volume, Excess, related to compromise of the cardiovascular system Risk for Trauma related to instrumentation-assisted birth Anticipatory Grieving related to fetal demise

Box 14-2 Factors Associated with an Increased Risk for Uterine Dystocia

Uterine abnormalities, such as congenital malformations and overdis-tention (e.g., hydramnios, multiple gestation)

Fetal malpresentation or malposition Cephalopelvic disproportion (CPD) Maternal body build (30 lbs. [13.6 kg] overweight, short stature) Uterine overstimulation with oxytocin Inappropriate timing of administration of analgesic/anesthetic agents Maternal fear, fatigue, dehydration, electrolyte imbalance

Source: Gilbert, E.S. (2006). Manual of high risk pregnancy and delivery. St. Louis, MO: C.V. Mosby.



hydromorphone (Dilaudid), and morphine (Cunningham et al., 2005). Natural labor with effective contractions often resumes after this simple intervention. Nonpharmacological techniques to reduce anxiety such as relaxation techniques, massage, a warm shower or tub bath, and increased emo-tional support are also helpful for some women.

For a woman whose fetus is in an occiputposterior position, the major goal of care is to facilitate rotation of the fetal head into a more favorable position. The nurse can encourage the laboring woman to walk and change positions frequently throughout the course of labor. The descent of the fetus into an anterior lie creates a better environment for normal labor progression.

Nursing care begins with a thorough assessment. It is critical to identify factors that contribute to increased maternal anxiety. Careful monitoring of contractions may provide early information regarding poor labor progres-sion and lead to timely interventions. While frequent checks for cervical dilation are not advisable, this assess-ment, when performed at proper intervals, provides a strong indicator of labor progression. Along with contin-ued assessment of the contraction pattern, the nurse can use this information to validate the fi nding of hypertonic labor. Once any intervention has occurred, the nurse evaluates the plan of care and, depending on the results, initiates appropriate measures.

Ethnocultural Considerations Communication diffi culties during labor

Nurses need to be sensitive to cultural differences among women experiencing hypertonic laborthose who are unable to speak or understand the English language may have diffi -culty communicating their feelings.

HYPOTONIC LABORHypotonic labor is a more common type of uterine dys-functional pattern that contributes to poor labor progres-sion. With hypotonic dystocia, the uterine contractions decrease in frequency and intensity. A hypotonic labor pattern usually occurs during the active phase of labor. It is defi ned as fewer than two to three contractions during

a 10-minute period. The uterus can be easily indented, even at the peak of the contraction, and the intrauterine pressure (IUP) is insuffi cient for the progression of cervi-cal effacement and dilation (Gilbert, 2006).

Hypotonic labor may be associated with a number of maternal and fetal factors that produce excessive uterine stretching and overdistention. For example, fetal macro-somia, multiple gestation, and hydramnios are all risk factors for hypotonic labor. Grand multiparity may also be a contributing cause.

Fetal macrosomia occurs in one fourth of all pregnan-cies and is the leading cause of uterine hypotonia. Macro-somia, defi ned as a fetus whose birth weight is above the 90th percentile on an intrauterine growth chart for that gestational age, often results from a fetal imbalance between glucose and insulin in women diagnosed with any type of diabetes. Over time, as increased amounts of glucose are absorbed from the mother, the fetus produces pancreatic insulin which results in an increase in fat deposits.

Maternal obesity unaccompanied by diabetes also con-tributes to a larger fetus. Hall and Neubert (2005) defi ne obesity as a woman who has a body mass index (BMI) of greater than 30 kg/m2. In their review of studies that examined obesity and pregnancy, direct links were found between maternal obesity and fetal macrosomia. The study fi ndings are consistent with data from Youngs and Woodmansees (2002) research, which demonstrated a positive relationship between an increased maternal BMI and fetal macrosomia.

Pharmacological agents used to alleviate pain during labor may also contribute to the risk of uterine hypotonia. If a labor pattern is not well established, these medications often halt or signifi cantly slow down the progress of labor. Various studies have produced confl icting data concerning a clear link between the use of analgesia, anesthesia, and the progress of labor. After administration of epidural anes-thesia, some women may experience a longer second stage of labor. The effects of the epidural may make it diffi cult for the patient to identify when to push and how long to push because the contractions are not always detected. However, nulliparous women who experience long and painful labors are more likely to choose epidural anesthesia for pain relief. Often it is diffi cult to document which factors contribute most signifi cantly to a protracted labor.

Minutes

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Infrequent contractions; poor intensity

Figure 14-1 Uterine contraction patterns. A. Normal uterine contraction pattern. B. Hypertonic uterine contraction pattern. C. Hypotonic uterine contraction pattern.

A

B

C



Nursing Insight Recognizing negative maternal effects of hypotonic labor

As an ineffective labor pattern continues, the woman is likely to become fatigued and may be at an increased risk for infection.

Depending on the cause, labor hypotonia is managed in different ways. Careful, ongoing assessments are key. If a diagnostic modality such as ultrasound examination has demonstrated that the womans pelvis is adequate for vagi-nal birth, measures to produce effective contractions are implemented. Walking and position changes in labor assist in fetal descent through the maternal pelvis and therefore need to be encouraged. The use of relaxation techniques, massage, and water treatments can decrease the need for pharmacological agents for pain.

Augmentation of labor contractions is considered when either the natural measures are unsuccessful or when it is deemed the best approach. At certain points in the labor, an amniotomy, or artifi cial rupture of the membranes, may be successful in increasing uterine contractility. Other measures to enhance the progress of labor include membrane stripping, nipple stimulation, and oxytocin infusion. Maternal and fetal assessments including vital signs, contraction patterns, and cervical changes need to be documented on a regular basis.

PRECIPITATE LABOR AND BIRTHContrary to both hypertonic and hypotonic labor, precip-itate labor contractions produce very rapid, intense con-tractions. By defi nition, a precipitate labor lasts less than 3 hours from the beginning of contractions to birth. Church and Hodgson (2003) report that multiparous women with little soft tissue resistance are at the greatest risk for this labor pattern. Patients often progress through the fi rst stage of labor with little or no pain and may pres-ent to the birth setting already advanced into the second stage. In a nulliparous patient, cervical dilation that occurs faster than 5 cm per hour is defi ned as precipitous labor. In a multiparous woman, cervical dilation may occur as rapidly as 10 cm in 1 hour. Precipitous labor may result from hypertonic uterine contractions that are tetanic in their intensity (Church & Hodgson, 2003).

Complications from a precipitate labor pattern result from trauma to maternal tissue and to the fetus because of the rapid descent. Hemorrhage may occur from uterine rup-ture and vaginal lacerations. Most women are ill prepared for the rapid advancement of their labor and become alarmed, highly anxious, and fearful. The fetus may suffer from hypoxia related to the decreased periods of uterine relaxation between the contractions and intracranial hemor-rhage related to the rapid birth (Cunningham et al., 2005).

Nursing ConsiderationsInitial assessments are paramount to establishing the pat-tern of precipitous labor. A multiparous patient with a previous history of rapid labors needs to alert her physi-cian or certifi ed nurse midwife (CNM) as soon as she rec-ognizes any signs of labor. Her prenatal record should include this information and be readily accessible to nurs-ing personnel managing her care. In a nulliparous patient, careful examination for cervical dilation and effacement is

required. Since a previous labor pattern is an unknown variable in the nulliparous patient, the nurse must be alert in recognizing signs of abnormally rapid cervical dilation (Church & Hodgson, 2003).

The woman and her support person need reassurance throughout the rapidly advancing labor. Breathing and relax-ation techniques are helpful tools that the nurse can use to assist the woman to cope with labor. If the patient and her family do not speak or understand the English language, it is incumbent on the nurse to request a translator. Precipitate labor is an anxiety-producing situation that is compounded by the womans inability to understand what is happening to her body. Although some precipitate labors occur with little or no pain, the patient is nevertheless aware of contractions that are occurring more quickly than normal. This experi-ence can be frightening. The woman may also have concerns regarding a loss of control over her labor. Continuous sur-veillance, frequent updates on her status, and reassurance about her condition can help to allay the patients anxiety. Medical management includes readiness on the part of the entire health team for the birth, particularly when the patient has a history of rapid labor. In most circumstances, a planned induction is part of the plan. Small dosages of intravenous analgesics may be used to help decrease pain.

The nurse can assist the woman in breathing through her contractions to avoid pushing and to help prevent tearing. If the nurse is alone with the patient during a precipitous delivery, the nurse follows delivery protocols when assisting in the birth of the infant. At the same time, the nurse uses the call bell to alert others for assistance. The nurse supports the perineum, assists the fetal head as it emerges, and checks for the umbilical cord as the head rotates. The newborns nose and mouth are suctioned; the shoulders and then the rest of the newborns body are sup-ported during the birthing process. The nurse assesses the neonates respiratory and cardiac rates.

After birth, whether assisted by the nurse or physician, the maternal soft tissue and placenta need to be carefully examined. The patient may require suturing of the cervix or vagina for lacerations. During the immediate postpar-tum period, the woman must be continuously monitored for hemorrhage. Providing ongoing information and sup-port assists the patient and helps her support person cope with this unexpected event (Church & Hodgson, 2003).

critical nursing action Assisting with a Precipitous Birth

The nurse who assists with a precipitous birth should take the following actions:

Request a translator to interpret for patients unable to speak or understand English.

Assist the laboring woman to breathe through each contraction to prevent pushing.

Provide continuous emotional support. Provide perineal support with warm cloths. Frequently monitor the maternal and fetal vital signs and

immediately report any abnormal fi ndings to the physician or certifi ed nurse midwife.

After birth, carefully monitor the patient for signs of hemorrhage; assess for trauma to the perineum.

Assess the neonate for evidence of trauma and report and document all fi ndings.



PELVIC STRUCTURE ALTERATIONSPelvic DystociaPelvic dystocia occurs when contractures of the pelvic diam-eters reduce the capacity of the bony pelvis, the midpelvis, the outlet, or any combination of these planes. Contractures of the maternal pelvis may result from malnutrition, neo-plasms, congenital abnormalities, traumatic spinal injury, or spinal disorders. In addition, immaturity of the pelvis may predispose some adolescent mothers to pelvic dystocia. Dur-ing labor, contractures of the inlet, midplane, or outlet can cause interference in engagement and fetal descent, necessi-tating cesarean birth (Cunningham et al., 2005).

Soft Tissue DystociaSoft tissue dystocia occurs when the birth passage is obstructed by an anatomical abnormality other than that involving the bony pelvis. The obstruction, which prevents the fetus from entering the bony pelvis, may be caused by placenta previa, uterine fi broid tumors (leiomyomas), ovar-ian tumors, or a full bladder or rectum. Bandl ring is a pathological retraction ring that develops between the upper and lower uterine segments. It is associated with protracted labor, prolonged rupture of the membranes, and an increased risk of uterine rupture (Cunningham et al., 2005).

TRIAL OF LABORA trial of labor (TOL) is the surveillance of a woman and her fetus for a set amount of time (usually 4 to 6 hours) dur-ing spontaneous active labor to assess the safety of a vaginal birth. Indications for a trial of labor include situations when the maternal pelvis is of questionable size or shape, when the fetus is in an abnormal presentation, and when the woman desires to have a vaginal birth after a previous (low-segment transverse) cesarean birth. Before the TOL, an assessment of the adequacy of the maternal pelvis for vagi-nal birth (to rule out cephalopelvic disproportion [CPD]) is conducted with sonography or maternal pelvimetry. The cervix must be favorable (soft, dilatable), and throughout the TOL, the woman is assessed for the presence of adequate contractions, engagement and descent of the fetal presenting part and cervical dilation and effacement.

Optimizing Outcomes Providing support during a trial of labor

Nursing responsibilities during a TOL include assessment of maternal vital signs and FHR and pattern. If complications arise, the nurse notifi es the primary health care provider, and evaluates and documents the maternalfetal responses to the interventions. Offering support and encouragement to the woman and her labor partner and ongoing information about labor progress are essential components of care.

Now Can You Discuss factors that impede the progress of labor?

1. Describe why maternal anxiety contributes to a lack of labor progression?

2. List three ways the nurse can reduce maternal anxiety?3. Identify which synthesizing enzymes are signifi cant to the

lack of myometrial contractility?

Obstetric Interventions

AMNIOINFUSIONPregnancy outcome in patients experiencing variable fetal heart rate (FHR) decelerations caused by cord com-pression is improved through the use of amnioinfusion, which is the instillation of normal saline or lactated Ringers solution into the uterine cavity. Amnioinfusion is used to supplement the amniotic fl uid volume in patients with oligohydramnios due to uteroplacental insuffi ciency, premature rupture of the membranes, and postmaturity; it may also be done to dilute meconium-stained amniotic fl uid (Fraser et al., 2005). Risks of the procedure include infection, overdistention of the uterus, and increased uterine tone.

Nursing Insight Understanding amnioinfusion as an intervention for meconium-stained amniotic fl uid

When there is evidence of moderate to thick meconium in the amniotic fl uid, amnioinfusion is used to dilute and help wash out the meconium to avoid neonatal meconium aspiration syndrome (Parer & Nageotte, 2004).

In most circumstances, the fl uid is instilled through an intrauterine pressure catheter (IUPC); the amniotic mem-branes must be ruptured for catheter placement. The fl uid may be warmed with a blood warmer before administra-tion and the infusion may be given by bolus or continuous fl ow. When possible, a double-lumen IUPC is used because the intrauterine pressure can be monitored without stop-ping the amnioinfusion.

Nursing considerations include careful monitoring of the infusion, the intensity and frequency of uterine con-tractions, and the maternal vital signs. In some institu-tions, patients are required to sign an informed consent prior to the intervention. It is important for the nurse to educate the woman and her support person regarding the need for the infusion and its purpose. Nurses must docu-ment the amount of the solution infused and the presence of any vaginal discharge (Gilbert, 2006).

critical nursing action When Caring for a Patient Undergoing Amnioinfusion

When caring for a patient undergoing amnioinfusion, the nurse must:

1. Assess the patients response to the fl uid infusion.2. Continually monitor the frequency and intensity of uterine contractions.3. Stop the infusion if the following signs and symptoms are noted:

maternal shortness of breath, an over distended uterus, hypotension, or tachycardia.

AMNIOTOMYAmniotomy, or the artifi cial rupture of membranes (AROM), is a nonpharmacological intervention that may be done to augment or induce labor or to facilitate the placement of internal monitors during labor. The procedure involves the insertion of an Amnihook or other sharp instrument into



the lower segment of the fetal membranes; following rup-ture, the fl uid is allowed to drain slowly (Fig. 14-2). The rupture of the membranes causes a release of arachidonic acid, which converts to prostaglandins, known inducers of labor through the stimulation of oxytocin in the uterus (Gilbert, 2006). Labor usually commences within 12 hours after artifi cial rupture. However, if labor does not ensue, there is an increased risk of infection; other risks include fetal injury and umbilical cord prolapse. Because of the risk for infection, amniotomy is frequently used in combination with oxytocin induction to facilitate delivery.

The nurse carefully monitors the patient who will undergo an amniotomy. Vital signs, cervical effacement and dilation, station of the presenting part, FHR, and contrac-tions are documented. The presenting part must be engaged and well applied to the cervix to prevent umbilical cord prolapse (protrusion of the umbilical cord in advance of the presenting part). There should be no evidence of active infection of the genital tract (e.g., herpes) or human immu-nodefi ciency virus (HIV) infection (Norwitz, Robinson & Repke, 2002).

Optimizing Outcomes Preparing the Patient for an Amniotomy

The nurse provides information, assesses the womans understanding of the procedure, and assures her that the membrane rupture will be painless to her and her fetus although she may experience some discomfort when the instrument is inserted through the vagina and cervix. The nurse ensures that the necessary equipment has been assem-bled: sterile gloves, lubricant, and the Amnihook or Allis clamp. After placing hip pads under the buttocks to absorb the fl uid, the nurse positions the woman on a padded bed-pan or with rolled up linens to elevate the hips. The nurse assists the health care provider performing the procedure by unwrapping and passing the equipment.

Immediately after the artifi cial rupture, the nurse notes and records the FHR and pattern. The color, odor, consis-tency, and clarity (and amount, if unusual) of the amniotic fl uid are also documented, along with the time of rupture

and the indication for the amniotomy. The patient may request analgesia or epidural anesthesia before the proce-dure. If she has not requested any medication, the nurse assists her with relaxation and breathing techniques dur-ing the contractions following the amniotomy because they are likely to be stronger.

Be sure to Monitor and document FHR during AROM

The nurse needs to assess the FHR immediately before and after the artifi cial rupture of membranes. Changes such as transient fetal tachycardia may occur and are common. However, other FHR patterns such as bradycardia and vari-able decelerations may be indicative of cord compression or prolapse.

Maternal temperature is assessed frequently (at least every 2 hours) after amniotomy to rule out infection. A temperature of 100.4F (38C) may be indicative of an infection and the health care provider should be notifi ed. Other signs and symptoms of infection include the presence of chills, uterine tenderness on palpation, foul-smelling vag-inal discharge, and fetal tachycardia (Simpson, 2005b).

Pharmacological Induction of Labor

INDICATIONS FOR INDUCTIONInduction of labor describes the use of chemical or mechanical modalities to initiate uterine contractions (before their spontaneous onset) to bring about child-birth. Induction of labor is considered when either a maternal or fetal condition exists that dictates the need for medical intervention in the labor process. According to Simpson and Atterbury (2003), labor induction often leads to an increase in interventionist care including the use of intravenous therapy, amniotomy, internal moni-toring, epidural anesthesia, and a longer stay in the labor unit. Martin et al. (2005) reported that since the year 1989, when data were fi rst collected, there has been a 125% increase in labor induction and a 75% increase in labor augmentation. Interestingly, non-Hispanic white women experience the highest rate of inductions. In 2003, the rate was 24.7%, while Asian or Pacifi c Islanders (14%) and Hispanic women (13.8%) experienced the lowest induction rates.

According to the American College of Obstetricians and Gynecologists (ACOG) the following maternal/fetal conditions serve as some of the indications for induction (ACOG, 1999):

Postterm pregnancy Maternal medical conditions (e.g., diabetes mellitus,

renal disease, chronic pulmonary disease, chronic hypertension)

Pregnancy-induced hypertension (PIH) Fetal demise Chorioamnionitis Premature rupture of membranes Fetal compromise (e.g., severe fetal growth restriction,

isoimmunization) Preeclampsia, eclampsia

Amnioticmembrane

Figure 14-2 An Amnihook is used to rupture the membranes.



Since induction carries certain risks, it is not per-formed without careful consideration and evaluation of the maternalfetal status. However, due to the rise in the U.S. cesarean rate over the last two decades, medical management of labor is commonly practiced in many hospitals to prevent the need for surgical delivery. This practice often involves admission of the patient with complete cervical effacement, rupture of the membranes, or expulsion of the mucus plug who is begun on a series of protocols that frequently include amniotomy com-bined with oxytocin infusion.

Induction of labor is more successful when the cervix is favorable, or inducible. The Bishop score is a rating system that may be used to determine the level of cervical inducibility. A series of points is awarded to cervical dila-tion, effacement, station, consistency, and position (Table 14-1). In general, labor induction is more likely to be suc-cessful with a higher score (9 or more for nulliparous women; 5 or more for multiparous women) (Cunningham et al., 2005; Glmezoglu, Crowther, & Middleton, 2006).

Cervical Ripening AgentsIf it is determined that the cervix is not favorable for oxy-tocin induction, a chemical cervical ripening agent using prostaglandin E1 (PGE1) (Misoprostol) or prostaglandin E2 (PGE2) (Dinoprostone [Prepidil, Cervidil]) may be prescribed (Table 14-2). These agents are most benefi cial when the patients Bishop score is greater than 6, although they are commonly used when the Bishop score is 4 or less. Before administration, informed consent may be required, according to agency protocol.

Misoprostol (Cytotec) is an analogue of prostaglandin E1. Available in tablet form, the medication is inserted into the posterior vaginal fornix. Misoprostol ripens the cervix, causing it to begin to dilate and efface. The U.S. Food and Drug Administration (FDA) has not approved the use of misoprostol for cervical ripening. Wing (2002) found miso-prostol to be an effective agent for cervical ripening and induction of labor that also decreases the amount of oxyto-cin required. Culver et al. (2004) concurred that misopros-tol is an effective cervical ripening agent but cited higher failure rates in nulliparous women with a low Bishop score and reported an increased incidence of uterine hyperstimu-lation with the medication. At least 4 hours after the last dose, oxytocin may be initiated for the induction of labor if cervical ripening has occurred and labor has not begun.

Dinoprostone, marketed as Cervidil Insert and Prepidil Gel, is an analogue of (PGE2). This cervical ripening agent makes the cervix softer, causing it to begin to dilate and efface and stimulate uterine contractions. PGE2 is used for preinduction cervical ripening when the Bishop score is 4 or less. Cervidil is applied into the posterior vaginal fornix; Prepidil is inserted through a syringe into the cervical canal just below the internal cervical os or into the posterior fornix. Cervidil acts more quickly. Uterine contractions usually begin in 5 to 7 hours after administration. When necessary, induction with oxyto-cin can be initiated 30 to 60 minutes after removal of the Cervidil insert. When using Prepidil gel, oxytocin induc-tion must be delayed until 6 to 12 hours after the last instillation of the medication. Cervidil has an added advantagethe insert can be removed if uterine hyper-stimulation occurs. Dinoprostone is FDA approved for cervical ripening.

Contraindications to the PGE1 and PGE2 cervical rip-ening agents include the presence of a non-reassuring FHR pattern, maternal fever, infection, vaginal bleeding, hypersensitivity, regular, progressive uterine contrac-tions, and a history of cesarean birth or uterine scar. The medications should be cautiously used in women with a history of asthma, glaucoma or renal, hepatic, or cardio-vascular disorders. After insertion, the nurse should clearly document all assessment fi ndings and adminis-tration procedures.

Mechanical MethodsMechanical methods provide another approach to cervi-cal ripening. Dilators placed in the cervix cause cervical ripening by stimulating the release of endogenous pros-taglandins. Rai and Schreiber (2005) cite the use of a balloon catheter (e.g., Foley catheter) placed into the intracervical canal to increase pressure exerted on the lower uterine segment. Hydroscopic dilators (those that enlarge as they absorb moisture from the surrounding tissue) such as laminaria tents (made from desiccated seaweed) and synthetic dilators containing magnesium sulfate (Lamicel) may be inserted into the endocervix without rupturing the membranes. The dilators remain in place for 6 to 12 hours before removal for assessment of cervical dilation. Fresh dilators may then be inserted if necessary. Amniotomy and membrane stripping (the physician or midwife inserts a gloved fi nger into the cer-vical os to gently strip the membranes) can be also be used to ripen the cervix.

OxytocinOxytocin, a hormone produced by the pituitary gland, stimulates uterine contractions. (See Chapter 12.) It can be used to induce labor or augment a labor that is progressing slowly due to ineffective uterine contractions. Administra-tion of the medication is closely monitored according to institutional protocols. An intravenous infusion of 0.5 to 2 milliunits per minute of oxytocin is used for labor induc-tion or augmentation. The dose is increased 1 to 2 milli-units per minute at intervals no less than 30 to 60 minutes until adequate labor progress is achieved. The patient should be reevaluated if the dose reaches 20 milliunits per minute (Deglin & Vallerand, 2009).

Table 14-1 The Bishop Score

Score

0 1 2 3

Dilation (cm) 0 12 34 5

Effacement (%) 030 4050 6070 80

Station (cm) 3 2 1 1, 2

Cervical consistency

Firm Medium Soft

Cervix position Posterior Midposition Anterior

Adapted from Rai, J., & Schreiber, J.R. (2005). Cervical ripenning. EMedicine. Retrieved from http://www.emedicine.com.



Optimizing Outcomes Through the safe administration of oxytocin

First, the patients primary health care provider writes an order for oxytocin for labor induction or augmentation. After an explanation and assessment of the patients level of understanding, the nurse assists the woman to a side-lying or upright position. Assessment of the patient and fetus is conducted and documented. The solution is pre-pared and administered with a pump delivery system according to the prescribed orders. The piggyback solu-tion is connected to the intravenous infusion at the port nearest the point of venous insertion. The medication is administered as ordered; ongoing assessments are con-ducted according to institutional protocol. The nurse documents the medication (kind, amount, times of beginning infusion, increasing the dose, maintaining the dose, discontinuing the infusion), maternalfetal reac-tions (FHR and pattern, maternal vital signs, pattern and

progress of labor, nursing interventions, and maternal response) and when notifi cation of the primary health care provider takes place.

Oxytocin acts on receptors in the myometrium to cre-ate an increase in the strength, duration, and frequency of the contractions. These same receptors are susceptible to uterine hyperstimulation, which constitutes a major risk associated with the medication. Signs of uterine hyper-stimulation include the following:

Uterine contractions that last greater than 90 seconds and occur more frequently than every 2 minutes

Uterine resting tone greater than 20 mm Hg Non-reassuring fetal heart and pattern (baseline less

than 100 or greater than 160 beats per minute; Absent variability; Repeated late decelerations or prolonged decelerations)

Table 14-2 Cervical Ripening Agents

Medication Action Adverse Effects Dosage

Prostaglandin E1

Misoprostol (Cytotec)

Induces labor contractions Diarrhea, abdominal pain, headaches, fever, tachysystole, uterine hyperstimulation

Intravaginally: 25 mcgrepeat every 46 hours until Bishop score equals 8 or greater.

Prostaglandin E2

Dinoprostone

(Cervidil Insert, Prepidil Gel)

Promotes initiation of cervical ripening

Uterine hyperstimulation, fever, back pain, headache, nausea and vomiting, diarrhea, hypotension, tachysystole

Cervidil Insert:

(10 mg dinoprostone gradually released over 12 hours). Remove after 12 hours or at labor onset. Keep insert frozen until ready to use.

Prepidil Gel:

(2.5-mL syringe containing 0.5 mg of dinoprostone). Repeat gel insertion in 6 hours as needed (maximum 1.5 mg or 3 doses/24 hr).

Allow gel to reach room temperature before administration; do not heat. Continue administration until maximum dose is reached, or uterine contractions are established (3/10 min) or Bishop score equals 8 or greater or adverse reactions occur.

May stimulate labor contractions Adverse effects are more common with intracervical administration.

Teaching: Patient Education

Assess knowledge of the medication.

Explain purpose of medication and side effects.

Discuss comfort options to offset side effects.

Instruct the patient to void before insertion.

Instruct the patient to maintain a supine position with a lateral tilt or side-lying position for 3040 minutes after insertion.

Sources: Deglin & Vallerand (2009) and Turkoski et al. (2004).



Higher doses are associated with an increased inci-dence of hyperstimulation; however, low dosages result in an increased rate of cesarean births due to failure of labor progression (Dudley, 2003). Uterine hyperstimulation causes reduced blood fl ow through the placenta and results in FHR decelerations, fetal asphyxia, and neonatal hypoxia. Because of the potential for life-threatening adverse complications associated with the use of oxytocin during the intrapartal period, the FDA has issued a num-ber of restrictions to its use.

c l in i ca l a ler t

Contraindications to the use of oxytocin to stimulate labor

Nurses should be aware of contraindications to the use of oxytocin to stimulate labor, which include, but are not limited to (ACOG, 1999): Vasa previa or complete placenta previa Transverse fetal lie Umbilical cord prolapse Previous transfundal uterine surgeryConditions that necessitate special precaution during oxytocin administration include: Breech presentation Multifetal pregnancy Presenting part above the pelvic inlet Severe hypertension Maternal heart disease Polyhydramnios One or more previous low-transverse cesarean deliveries Abnormal fetal heart rate patterns not necessitating emergent

delivery

Augmentation of labor is used to stimulate uterine contractions after labor has begun spontaneously but is not progressing satisfactorily. It is most commonly indi-cated for the management of hypotonic uterine dys-function. Labor augmentation may be accomplished with amniotomy, oxytocin infusion, and nipple stimula-tion. Noninvasive approaches include ambulation, hydration, relaxation, and hydrotherapy and these methods should be attempted before the initiation of invasive measures.

Nipple stimulation has been used for labor augmenta-tion and induction. The action of nipple rolling produces an increase in the release of oxytocin from the anterior pituitary gland. The nurse instructs the woman to roll her nipple through her clothing for ten minutes on one side and then proceed to the other side, resting during a con-traction. A breast pump may also be used. Nipple stimula-tion rarely causes hyperstimulation of the uterus. How-ever, the results of nipple stimulation are less predictable than the administration of specifi ed dosages of oxytocin. Sexual intercourse has also been helpful as a method of induction because semen contains prostaglandins (Gilbert, 2006). Both of these methods require additional evidence-based research before their endorsement as viable alterna-tives for labor induction.

Complementary Care: Measures for induction of labor

Several nonpharmacological methods or alternative methods have been used to induce labor. Herbal remedies such as black haw, primrose oil, black and blue cohosh, chamomile, and red raspberry leaves are prescribed as labor inducers in some cultures. Technically these substances are medicinal agents with some properties similar to those of oxytocin. Use of these agents creates problems because of the lack of scien-tifi c research and validation of their effectiveness. Much of the information about how they work is anecdotal, which also makes it diffi cult to evaluate the risks and the benefi ts, critical information for patients and their health care provid-ers (Tenore, 2003). Nonherbal methods include acupunc-ture, the ingestion of a laxative (e.g., castor oil), and the stripping of membranes.

NURSING CONSIDERATIONSThe nurses responsibilities during labor induction or aug-mentation begins with obtaining informed consent for the procedure after physician explanation. Patient education regarding the procedure and its consequences is critical. Monitoring of the labor is essential since hyperstimulation of the uterus may lead to uterine rupture. Oxytocin proto-cols in many institutions require that the nurse remain at the patients bedside at all times for careful surveillance. The following data should be placed on a fl ow sheet in the patient record:

Patients vital signs (blood pressure, pulse and respira-tions every 30 to 60 minutes and with every increment in medication dose)

FHR (via electronic monitoring) Frequency, duration, and strength of contractions

(note contraction pattern and uterine resting tone every 15 minutes and with every increment in medication dose during fi rst stage; then monitor every 5 minutes during second stage)

Cervical effacement and dilatation Fetal station and lie Rate of oxytocin infusion Intake and urine output (limit intravenous fl uid intake

to 1000 mL/8 hr; output should be 120 mL or more every 4 hours)

Any untoward effect of the medication administration (nausea, vomiting, headache, hypotension)

Psychological response of the patient (ACOG, 1999; Gilbert, 2006; Simpson, 2005b).

critical nursing action Recognizing and Responding to Problems During Labor Induction with Oxytocin

During induction of labor with oxytocin, the nurse remains alert to signs indicative of complications such as uterine hyperstimulation, non-reassuring FHR pattern, and suspected uterine rupture. Immediate emergency measures include: discontinuing the oxytocin per institu-tional protocol; positioning the patient on her side; increasing the



primary IV rate up to 200 mL/hr (unless there is evidence of water intoxicationin this situation, the rate is decreased to one that keeps the vein open); administering oxygen by face mask at 810 L/min or per physician order or institutional protocol.

The nurse needs to discuss pain relief options with the patient before oxytocin administration. The infor-mation presented should include prescribed medica-tions as well as natural options. If the woman declines pharmacological analgesia or anesthesia, the nurse must work closely with her and her support person in the effective use of relaxation and breathing techniques. The woman placed on bedrest as a result of the induc-tion needs frequent position changes. Massage may enhance her comfort during the procedure. The nurse should keep the patient and her support person informed of her progress as this information reassures the patient and gives her confi dence.

Now Can You Discuss labor induction?

1. Identify eight indicators for labor induction?2. Explain the relationship between the Bishop score and

induction of labor?3. Identify and discuss the implications of pertinent data

recorded on the maternal fl ow sheet during labor induction with oxytocin?

INSTRUMENTATION ASSISTANCE OF BIRTHForceps and vacuum extraction are used to decrease the length of the second stage of labor when indicated because of maternal exhaustion or epidural anesthesia, suspected fetal distress, and the need to rotate the fetal head. In the United States there has been a decrease in the overall use of instrumentation as a birth assist while there has been an increase in operative deliveries. Specu-lation as to the reason for this trend has been attributed to a fear of malpractice related to complications associ-ated with the methods as well as a lack of physicians training in the use of delivery instrumentation (Patel & Murphy, 2004).

Forceps-Assisted BirthA forceps-assisted birth is one in which a steel instrument with two curved blades is used to facilitate the birth of the infants head. Forceps is an instrument consisting of cephalic-curved blades similar to the shape of the fetal head (Fig. 14-3). The two blades slide together at the shaft to form a handle. The fi rst blade is inserted into the maternal vagina next to the fetal head. The second blade is then inserted and applied to the opposite side of the fetal head. The shafts of the forceps are brought together in the mid-line and secured to form a handle. Forceps prevent pressure from being exerted on the fetal head and facilitate birth.

Maternal indications for a forceps-assisted birth include a need to shorten the second stage of labor for the follow-ing reasons: dystocia; an inability to push with contrac-tions (e.g., due to exhaustion, spinal or epidural anesthe-sia, spinal cord injury); to prevent worsening of serious

medical complications such as cardiac compensation. Fetal indications include an abnormal presentation, arrest of rotation, immaturity, and distress from a complication such as prolapsed cord.

There are various applications and several different types of forceps for forceps-assisted birth. Outlet forceps are used when the fetal scalp is visible on the maternal perineum without manual separation of the labia. Low forceps are used when the fetal head is at a 2 station or more. Midforceps are used when the fetal head is engaged but at less than a 2 station. Because birth trauma has been associated with the use of midforceps, this proce-dure has been largely replaced by cesarean birth, which poses less risk to the fetus. Forceps are never applied to an unengaged presenting part. Piper forceps are used to facilitate delivery of the head in a breech birth. Some form of anesthesia is administered before forceps applica-tion to achieve pelvic relaxation and decrease pain. An episiotomy is usually performed to prevent perineal tear-ing. Before forceps application, the following criteria must be met:

The cervix must be fully dilated; bladder empty; presenting part engaged

The membranes must be ruptured Cephalopelvic disproportion must not be present

critical nursing action When Attending a Forceps-Assisted Birth

The FHR and pattern are assessed and recorded before the forceps application. When the forceps are applied, there is a danger of com-pression of the cord between the fetal head and the forceps blade. Cord compression causes a decrease in FHR. Therefore, assess and record the FHR and pattern again immediately after the forceps application.

Perineal trauma is one of the major complications asso-ciated with the use of forceps. Since hemorrhage may result from cervical lacerations and vaginal tearing, the woman requires close observation during the postpartum period. To rule out maternal bladder injury, the nurse documents the time and amount of the fi rst postbirth voiding. Some women have reported fecal incontinence following forceps injury. Women who experience forceps-related problems may suffer fear and anxiety regarding the birth experience in subsequent pregnancies (Patel & Murphy, 2004).

Fetal morbidity occurs in direct response to occipital trauma. Superfi cial scalp and facial markings are the most common complications and are rarely signifi cant. However, it is important for the nurse to clearly discuss this possibility with the family. Once the parents under-stand that the trauma marks gradually disappear, they are usually more accepting of the babys (usually) super-fi cial injuries. Other forceps-related complications that rarely occur include facial nerve injury, cephalhema-toma, retinal hemorrhage, and ocular trauma. Neonatal intracranial bleeding constitutes a major concern but it is often diffi cult to ascertain whether the hemorrhage resulted from the forceps or it was related to the diffi cult birth (Belfort, 2003).



Now Can You Discuss issues surrounding the use of forceps?

1. Identify three maternal indications and three fetal indications for a forceps-assisted birth?

2. Describe maternalfetal complications associated with the use of forceps instrumentation?

3. Discuss key information the nurse provides the parents regarding a forceps-assisted birth?

Vacuum-Assisted BirthVacuum-assisted birth, also termed vacuum extraction, is an alternative method used in an assisted vaginal delivery (Fig. 14-4). The vacuum extractor consists of a soft plas-tic cup that is attached to the fetal head over the posterior fontanel and a suction apparatus that uses negative pres-sure to facilitate the birth of the head. This modality is used for a patient who is unable to voluntarily push dur-ing the second stage of labor (most often due to exhaus-tion or pharmacological agents), fetal distress or failure to progress. The same conditions apply to the use of the vacuum as for forceps: vertex presentation, ruptured membranes, and absence of CPD. Vacuum-assisted birth has certain advantages over forceps-assisted birth: little anesthesia is required (the fetus is less depressed at birth) and it is associated with fewer lacerations of the maternal birth canal. Vacuum extraction should not be used

following fetal scalp blood sampling. The suction pres-sure can cause excessive bleeding at the sampling site. It is also not recommended for preterm fetuses whose skulls are extremely soft.

To prepare the patient for a vacuum-assisted birth, the nurse provides education and support and encourages the womans continued participation in childbirth by pushing during contractions. The FHR is assessed before and throughout the procedure. The nurse assists the woman to a lithotomy position to allow suffi cient traction. The primary care provider applies the cup to the fetal head and a caput (swelling of the soft tissue) develops inside the cup as the pressure is initiated. Gentle traction is applied to facilitate descent of the fetal head. An episiotomy may be performed as the head crowns.

Be sure to Assume nursing responsibilities associated with a vacuum-assisted birth

The nurse is responsible for management of care during a vacuum-assisted procedure. Although the physician applies the vacuum to the infant head, the nurse controls the vac-uum gun and the pressure and is responsible for all of the required documentation. The perinatal team must com-municate frequently during the procedure as they each assess progress or the lack of progress. The nurse, follow-ing protocols, can advocate for cesarean birth if maternal exhaustion and/or failure of descent indicates that the

Simpson forceps (outlet)

Fenestrated bladesShank

Handle

Tucker-McLean forceps (outlet)

Solid blades Shank Handle

Lock

Piper forceps(aftercoming head in breech)

Fenestrated blades

Shank Handle

Direction of gentletraction for outletforceps delivery

Figure 14-3 Forceps are instruments with curved blades that are used to facilitate the birth of the fetal head.



vacuum assistance is not effective. If the nurse fails to communicate concerns and there is an untoward event, the nurse can be held liable. Liability is also incurred if the nurse fails to document the sequence of events during the vacuum assistance along with the maternalfetal response. After an assisted birth, the nurse who assesses the neonate is also liable with regard to the documentation of vital signs and the neonatal assessment (Mahlmeister, 2005).

The caput that has formed on the neonates scalp begins to disappear in several hours but may persist for up to 7 days after birth. Appropriate education of the parents before the vacuum application helps them to understand that the caput swelling is not harmful to the infant and the markings will decrease rapidly. Neonatal complications include cephalhematoma, scalp lacera-tions, and subdural hematoma. The infant should be carefully observed for signs of trauma and infection at the application site.

Maternal Conditions that Complicate Childbirth

HYPERTENSIVE DISORDERSManagement of hypertensive disorders during parturition is based on two goals: preventing further deterioration of affected organs and fostering a positive maternal-infant outcome. Women who have been diagnosed with severe

preeclampsia or HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets; see Chapter 11) may be placed in an obstetric critical care unit or a medical inten-sive care unit for hemodynamic monitoring. Maternal vital signs, FHR, urine output, deep tendon refl exes, level of edema, and mental orientation and neurological status are assessed. Fetalmaternal factors that may necessitate immediate interventions to facilitate birth are presented in Box 14-3.

When severe preeclampsia is diagnosed at less than 34 weeks gestation, the approach to care may include an observational period and conservative management. If the gestational age is 32 to 35 weeks, induction of labor is usually initiated. Vaginal birth is considered safer than cesarean birth and is attempted if cervical favorability is present. Antenatal glucocorticoids such as betametha-sone may be given (12 mg IM 24 hours apart) to promote lung maturity if the gestational age is less than 34 weeks and delivery can be delayed for 48 hours (ACOG, 2002a; Cunningham et al., 2005; Sibai, Dekker, & Kuperminic, 2005). (See Chapter 11.)

Nursing ConsiderationsThe nurse is the manager of care for the woman with pre-eclampsia during the intrapartal period. Careful assess-ments are critical. The nurse plans and evaluates all inter-ventions on a continuous basis. The patient with severe preeclampsia is in an extremely fragile condition. Since any change in condition may require an emergency interven-tion, the nurse must be prepared to provide the necessary care immediately. The nurse is responsible for the continu-ous monitoring of several key parameters (Box 14-4). Labo-ratory tests include a complete blood count (CBC) with platelets, coagulation profi le to assess for disseminated intravascular coagulation (DIC), metabolic studies for determination of liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], lactate dehydroge-nase [LDH]) and electrolyte studies to establish renal func-tioning (ACOG, 2002). (See Chapter 11 for further discussion.)

Box 14-3 Factors that May Necessitate Immediate Intervention to Facilitate Birth in Patients with Hypertensive Disorders

Uncontrolled severe hypertension Eclampsia Persistent oliguria ( 500 mL/24 hr) Abruptio placentae Platelet count less than 100,000/mm3

Elevated liver enzyme levels with epigastric pain or right upper quad-rant tenderness

Pulmonary edema Persistent severe headache or visual changes Spontaneous labor Fetal death Rupture of the membranes Gestational age less than 34 weeks (an observational period may be

initially attempted as a conservative management approach) Evidence of fetal compromise

Figure 14-4 Vacuum extraction also facilitates the delivery of the fetal head and is associated with fewer lacerations of the maternal birth canal. A. Vacuum extractor is applied with a downward and outward traction. B. A caput succedaneum, or chignon, is formed from the suction cup.

A

B



The nurse must also monitor the laboratory values for impending HELLP syndrome during labor. The nurse follows the plan of care for the patient with severe preeclampsia.

Special precautions need to be considered to prevent adverse outcomes in a patient with the HELLP syndrome who requires a cesarean birth. The nurse is responsible for administering 5 to 10 units of platelets on the physicians order before the birth to prevent thrombocytopenia. Pro-viding ongoing information to the patient and her family is an essential nursing intervention to help decrease anxi-ety and fear (Sibai et al., 2005).

DIABETESWomen with the metabolic disorder of diabetes that is under control may safely give birth spontaneously at term provided there are no indications of severe cephalopelvic disproportion (CPD). When a possibility of CPD exists, the diabetic woman may be given a trial of labor. If suc-cessful, a cesarean birth, which always presents a higher risk than a vaginal birth for the fetus, has been avoided.

Nursing Insight Recognizing medical indications for elective preterm birth in women with diabetes

As long as she remains in good metabolic control and all param-eters of fetal surveillance are within normal limits, the woman whose pregnancy is complicated by diabetes may safely carry the pregnancy to 38.540 weeks of gestation. However, the presence of poor metabolic control, a worsening hypertensive disorder, fetal macrosomia (often defi ned as weight 4500 g) or fetal growth restriction are all indications for elective pre-term birth (ACOG, 2001; Cunningham et al., 2005).

The physician may plan an elective induction of labor between 38 and 40 weeks of gestation. An amniocentesis performed between 37 and 38.5 weeks of gestation is per-formed to confi rm fetal lung maturity. Fetal lung matura-tion is better predicted by an amniotic fl uid phosphatidyl-glycerol level of greater than 3% than by an amniotic fl uid lecithin/sphingomyelin ratio (3:1) in the pregnancy com-plicated by diabetes. If the fetal lungs are immature, birth may be delayed as long as all parameters of the maternal and fetal assessment remain reassuring (Moore, 2004). (See Chapter 11.)

Intrapartum management for the woman with preges-tational diabetes centers on the close surveillance of maternal hydration and blood glucose levels to prevent complications associated with dehydration, hypoglyce-mia, and hyperglycemia. An intravenous infusion of a maintenance fl uid such as lactated Ringers solution or 5% dextrose in lactated Ringers solution may be ordered. Insulin is usually administered by continuous infusion; only regular insulin may be administered intravenously. Blood glucose levels are assessed every hour and fl uid/insulin adjustments are made as needed to maintain maternal blood glucose levels between 80 and 120 mg/dL (Bernasko, 2004). It is essential that maternal hyperglyce-mia during the intrapartal period be avoided to prevent neonatal metabolic problems such as hypoglycemia.

Box 14-4 Intrapartal Nursing Care for Patients with Preeclampsia

BLOOD PRESSUREThe blood pressure is taken every 4 hours or more frequently according to physician orders or institutional protocol. Blood pressure should be taken in the same arm at each assessment. Encourage the patient to assume a side-lying position to enhance uterine perfusion. Record the data. Notify the physician of an increase in blood pressure.

MEDICATION ADMINISTRATIONAdminister medication as ordered and evaluate its effect. Adhere to hos-pital protocol for magnesium sulfate infusion. Monitor maternal vital signs, FHR, urine output, DTRs, IV fl ow rate and serum magnesium levels to assess for magnesium sulfate toxicity (e.g., depressed respirations, hyporefl exia, sudden onset of hypotension, oliguria, indicators of fetal compromise). Administer calcium gluconate (the antidote for magnesium sulfate toxicity) for respirations below 12 breaths/min and discontinue the magnesium sulfate infusion.

RENAL BALANCEEdema is rated on scale of 1 to 4. A score of 4 is generalized massive edema that includes the face, abdomen and sacrum. Assess and record urinary output. An indwelling urinary catheter may be inserted to more accurately measure urinary output. A urine output less than 30 mL/hr is indicative of oliguria and the physician must be notifi ed. A dipstick mea-surement is performed every 4 hours or more frequently to assess urinary protein on a scale of 14. A dipstick reading over 2 is indicative of a worsening condition.

NEUROLOGICAL STATUSDeep tendon refl exes (DTRs) are assessed every 4 hours (or more fre-quently) and rated on a scale of 1 to 4. Refl exes greater than 2 are a sign of worsening status. If dorsifl exion of the foot produces clonus (convulsive spasm), this fi nding provides an additional indication of a deteriorating maternal condition.

PULMONARY STATUSAuscultation of the lungs is performed every 4 hours (or more frequently) to assess for dyspnea, crackles and diminished breath sounds, which may be indicative of pulmonary edema. The respiratory rate is assessed every 4 hours (or more frequently). Patients who are receiving magnesium sulfate require more frequent respiratory assessments since a respiratory rate below 12 is an indicator of magnesium toxicity. Hemoglobin oxygen saturation can be assessed with a pulse oximeter.

PSYCHOLOGICAL STATUSAssess the woman for indicators of anxiety and fear. Provide information to the patient and family about the treatment protocols and status of the maternal condition. Assess their level of understanding and provide updates when indicated.

ADVANCING SYMPTOMSHeadaches, blurred vision, severe right upper quadrant epigastric pain, and restlessness are all indicators of impending eclampsia. Prepare for immediate delivery.

SEIZURESProtect the patient. Keep the airway patent: turn head to one side and place pillow or folded linen under one shoulder or back. Call for assis-tance. Ensure that the siderails have been raised. Observe and document all seizure activity. Notify the physician and prepare for delivery. Adminis-ter oxygen.

FETAL STATUSMonitor the fetal heart rate every 4 hours or more frequently as indicated. Assess fetal movements. Notify the physician if indicators of fetal compromise are noted.



The laboring patient is maintained in an upright or side-lying position with continuous FHR monitoring. Nursing care involves close surveillance for indicators of normal labor progression along with a stable maternalfetal unit. Failure to progress may be related to fetal macrosomia or CPD and necessitate a cesarean birth. Diabetes-related complications such as hyperglycemia, ketosis, and ketoacidosis may develop and must be promptly managed. Shoulder dystocia associated with fetal macrosomia may complicate the second stage of labor. A team that consists of the obstetrician and neona-tologist, pediatrician, or neonatal nurse practitioner should attend the birth to provide immediate neonatal assessment and care.

When a cesarean birth has been planned, the surgery is scheduled for the early morning to achieve optimal glyce-mic control. Depending on physician orders, the nurse may be instructed to withhold the morning insulin. Other protocols allow administration of an intermediate-acting insulin in the morning and every 8 hours until surgery (Chan & Winkle, 2006). The patient is allowed nothing by mouth. Epidural anesthesia is preferred because hypo-glycemia can be detected earlier if the woman remains awake. After the surgery, maternal blood glucose levels are assessed at least every 2 hours; target plasma levels are between 80 and 160 mg/dL (Moore, 2004).

The fi rst 24 hours postpartum are remarkable for the dramatic decrease in insulin requirements that occurs after removal of the placenta. Depending on the amount of food consumed, women with type I diabetes may require only one fourth to one third of the prenatal insulin dose (Bernasko, 2004). Some women may not require insulin for 24 to 72 hours postpartum (Chan & Winkle, 2006). Throughout the postpartal period, blood glucose levels continue to be monitored and insulin dosage adjustments are made as needed, often using a sliding scale.

Nursing Insight Increased risk of postpartal complications in diabetic women

Women whose pregnancies have been complicated by diabetes have an increased risk for complications such as preeclampsia/eclampsia, hemorrhage, and infection (i.e., endometritis) dur-ing the postpartal period. Hemorrhage is more likely if the uterus was overdistended due to fetal macrosomia or hydram-nios. (See Chapter 16.)

The nurse should encourage mothers with pregesta-tional and gestational diabetes to breastfeed. However, because glucose levels are lower, especially during early postpartum, breastfeeding women are at an increased risk for hypoglycemia. Also, the mother with poor metabolic control may have a delay in lactogenesis that results in decreased milk production (Moore, 2004).

Discharge planning for women with diabetes should include discussion about contraceptive information as appropriate. Because women with gestational diabetes are at increased risk for developing diabetes later in life, the nurse should counsel them about the importance of main-taining a healthy weight and undergoing glucose testing during routine health maintenance visits.

PRETERM LABOR AND BIRTHPreterm labor that is not arrested leads to preterm birth. In the United States, preterm birth has increased over the last decade despite the use of preventive pharmacological therapies. Martin et al. (2005) reports that in 2002, 12.3% of infants born were preterm. This fi gure is the highest number recorded since preterm birth data have been col-lected. Accompanying this dramatic increase in preterm births is a 50% increase in premature infants born with neurological defi cits (ACOG, 2003a).

Ethnocultural Considerations Preterm labor and birth

Race and ethnicity cannot be disregarded in any discussion of preterm labor. Black women are at a higher risk for preterm birth than are Caucasian women. When preterm birth rates of married, educated Black women are compared with those of matched Caucasian women, a disparity continues to be noted in the Black women. The increase in cases of preterm labor results in a greater percentage of infant mortality in the Black population (Moore, 2003).

The causes for preterm birth are often a series of over-lapping conditions such as premature rupture of mem-branes combined with cervical incompetence. Canavan, Simhan, and Cartis (2004) reported that premature rup-ture of the membranes accounts for approximately 3% of all preterm births. In many cases, patients experience silent (asymptomatic) uterine contractions throughout pregnancy that contribute to progressive cervical efface-ment and dilation. (See Chapter 11.)

Although interventions including bedrest, hydration, and tocolytic therapy are used to inhibit contractions, in many situations the labor cannot be halted. If the womans membranes have ruptured or if the cervix is greater than 50% effaced and 3 to 4 cm dilated, it is unlikely that the labor can be stopped. If the fetus is very immature and birth is deemed to be inevitable, a cesarean birth may be planned to reduce pressure on the fetal head and decrease the possi-bility of subdural or intraventricular hemorrhage.

Nursing ConsiderationsIn addition to careful maternal monitoring, FHR monitor-ing is one of the most important nursing responsibilities when caring for a patient in preterm labor. A number of perinatal complications such as preeclampsia, intra-amniotic infection, oligohydramnios, umbilical cord com-pression, placental abruption, intrauterine growth restric-tion, uteroplacental insuffi ciency, and multiple gestation occur more often with preterm labor. This combination of complications may result in FHR patterns that differ from the norm. Because of the increased incidence of neurolog-ical defi cits in premature infants, it is essential that the nurse be able to identify and report data suggestive of hypoxia as early as possible (Simpson, 2004).

Best clinical practice for fetal monitoring begins with cor-rect application of the tocodynamometer and the fetal heart monitor. Leopold maneuvers are used to identify the fetal back and presenting part. Since multiple gestations are often associated with preterm labor, it is important to identify and



monitor each fetus. The tocodynamometer needs to be placed at the height of fundus to ensure the best interpreta-tion of the labor contractions (Simpson, 2004).

Optimizing Outcomes Providing pain relief during preterm labor and birth

The length of the fi rst stage of labor for a woman who is pre-term is essentially the same as for a woman with a full term gestation although the second stage may be shorterthe smaller fetal size can be pushed through the dilated cervix more easily. Maternal analgesia is used cautiously due to the immaturity of the fetus, who may have considerable diffi -culty breathing without the additional burden of sedative effects from maternal analgesic agents. If the patient desires analgesia, the nurse can explain why epidural pain relief is most likely preferable. An episiotomy is often performed at the time of birth to lessen trauma on the fragile fetal head; forceps may also be used.

Because of the patients medical complications and related fetal issues, she and her support person often experience increased anxiety and fear during the labor and birth. The nurse is there to offer clinical expertise; provide a calming presence; and inform, support, and assist the patient and her partner throughout the birth experience. A careful assessment of the patients psycho-logical status can help direct the care. Expressions of car-ing coupled with dialog that includes specifi c questions help to identify the patients main concerns.

Optimizing Outcomes Exploring concerns of the woman experiencing preterm labor

The nurse should use active listening and remain nearby. The patient should be encouraged to participate in decision making as much as possible throughout the labor process. Women who have anticipated an uncomplicated labor and birth experience often feel out of control when events occur that differ from their expectations. The nurse can play a vital role in keeping the patient informed and helping her to remain an active participant throughout the birth process. One approach involves teaching the patient and her partner what to expect during each phase and how they can help one another throughout the process. If the patient so wishes, the nurse involves the support person in the care as much as possible.

Ethnocultural Considerations Minority women and level of care received

The Institute of Medicine (2003) reported that minorities do not receive the same level of quality care as do white Americans. A nurse working in the birth unit needs to be attentive to this prob-lem. It is incumbent on all nurses to advocate for patients any time there appears to be an ethnic bias in treatment. The nurse also must be aware of any of personal prejudices that could affect care. In institutions that serve minority populations, it is essential that all hospital staff members undergo frequent in-service edu-cational offerings that focus on heightening cultural sensitivity.

Now Can You Discuss aspects of various maternal conditions that complicate childbirth?

1. Discuss critical aspects of intrapartal care for the woman with diabetes?

2. Describe one critical nursing responsibility in the patient experiencing a nonarrested preterm labor?

3. Identify three teaching needs for the patient experiencing preterm labor and birth?

Complications of Labor and Birth Associated with the Fetus

FETAL MALPRESENTATIONFetal malpresentation is the second most commonly reported complication of labor and birth. In 2003, it occurred at a rate of 38.5 per 1000 live births (Martin et al., 2005). The fetal occiput is the most favorable presenting part for a vaginal birth. Face, brow, shoulder, compound, and breech constitute malpresentations. A breech presen-tation, in which the buttocks or legs present fi rst, occurs in approximately 3% of all births and is considered the most common malpresentation. (See Chapter 12.) It is impor-tant that these conditions be identifi ed during the antepar-tum period since a malpresentation may place the woman and fetus at risk for complications during labor and birth. Diagnosis is made by abdominal palpation (i.e., Leopold maneuvers) and vaginal examination and is usually con-fi rmed by ultrasonography.

During labor, descent of the fetus in a breech presenta-tion may be slow. This is because the breech is not as effective as a dilating wedge as the fetal head. There is an increased risk of prolapsed cord if the membranes rupture during early labor (Fig. 14-5).

Nursing Insight Breech presentation and meconium in the amniotic fl uid

When the fetus is in a breech presentation, the presence of meconium in the amniotic fl uid may not be indicative of fetal distress. Pressure exerted on the fetal abdomen during the birth process may cause the passage of meconium. It is important to assess the FHR and pattern to ensure there are changes indica-tive of fetal hypoxia. When the fetus is in a breech position, the FHR is best auscultated at or above the maternal umbilicus.

During the vaginal birth of a fetus in a breech presenta-tion, the physician uses labor mechanisms that manipu-late the buttocks and lower extremities. Piper forceps are sometimes applied to facilitate delivery of the head. Before the birth, the physician may attempt an external cephalic version to rotate the fetus to a vertex presentation. (See later discussion.) Cesarean birth is commonly performed when the following circumstances exist: the fetus is esti-mated to be larger than 3800 g or smaller than 1500 g; the labor is ineffective; this is the womans fi rst pregnancy; or there are additional maternalfetal complications.

Face and brow presentations are examples of asynclitism (the fetal head is presenting at a different angle than



Figure 14-5 The mechanisms of labor in a breech presentation. The aftercoming fetal head delivers last.

expected). Face and brow presentations hyperextend the neck and increase the overall circumference of the presenting part. These presentations are uncommon and are usually associated with fetal anomalies (i.e., anencephaly), macroso-mia, CPD, and contractures of the maternal pelvis. Vaginal birth may be accomplished if the fetus fl exes to a vertex pre-sentation. Forceps are often used. Cesarean birth is indicated if the presentation persists, if there is evidence of fetal compromise, or if there is an arrest in the progression of labor. Shoulder and compound presentations (e.g., a hand combined with the head) contribute to fetal and vaginal trauma and usually require cesarean birth (Cunningham et al., 2005).

VERSIONVersion (turning of a fetus from one presentation to another) may be done either externally or internally by the physician.

External VersionAn external cephalic version (ECV) is used as an attempt to turn the fetus from a breech presentation to a vertex presentation to allow a vaginal birth (Fig. 14-6). Since cesarean birth is a major surgical procedure associated with numerous maternal and fetal risks, ECV may offer an alternative to surgery. The procedure, performed in a birth unit, may be attempted after 37 weeks gestation. Contraindications to ECV include previous cesarean birth,

uterine anomalies, CPD, placenta previa, multifetal gesta-tion, and oligohydramnios (Cunningham et al., 2005).

Before the version, ultrasonography is obtained to con-fi rm the fetal position, locate the umbilical cord; rule out placenta previa; assess the maternal pelvic dimensions and the amniotic fl uid volume, fetal size and gestational age, and the presence of anomalies. Before the version, a non-stress test (NST) is performed to confi rm fetal well-being, or the FHR may be electronically monitored for a brief period (e.g., 10 to 20 minutes).

Ultrasound guidance is used as the physician slowly applies gentle, steady pressure over the fetal head and but-tocks to rotate the position. Complications associated with version include umbilical cord compression, placen-tal abruption, maternal hemorrhage, and fetal bradycardia (Vadhera & Locksmith, 2004).

The procedure of rotating the fetus (version) requires uterine relaxation. Tocolytic agents such as magnesium sulfate or terbutaline are used to facilitate this process. Acoustic stimulation of the fetus has also resulted in suc-cessful versions (Vadhera & Locksmith, 2004).

Optimizing Outcomes Assisting with ECV

The nurse is responsible for obtaining written informed consent from the patient after physician explanation, providing teaching regarding the procedure, administer-ing medications as ordered, and conducting constant surveillance of the maternalinfant dyad. The patient



needs to know not only that the version attempt might not be successful; she must also be aware of the associ-ated complications that may occur such as rupture of the membranes, fetal bradycardia, and discomfort. During the version, if there is any indication of signifi cant fetal or maternal compromise, the nurse prepares the woman for a cesarean birth. Women who are Rh-negative are given Rh immune globulin because the manipulation may cause fetomaternal bleeding (Bowes & Thorp, 2004; Vadhera & Locksmith, 2004).

Internal VersionWith internal version, the physician rotates the fetus by inserting a hand into the uterus and changes the fetal presentation to cephalic (head) or podalic (foot). Inter-nal version is used with multifetal gestations to deliver the second fetus. However, the safety of this procedure has not been documented. Cesarean birth is usually per-formed for

maternal nursing care- chpt 14 caring for women with complications during labor

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