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Caring for the Woman Experiencing Complications During Labor and Birth

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

chapter

14

LEA R NING T AR G ET S 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 health
Ray, 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 syndromes, 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 disease before their rst documented delivery. The sample, obtained

through multiple databases, consisted of women admitted to the hospital for the 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 cardiovascular disease in the 24 months preceding the birth were excluded. Maternal placental syndrome included preeclampsia, gestational 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 identied as the point for determining the composite for the development of cardiovascular disease.
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moving toward evidence-based practice (continued) Data analysis revealed the following 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 syndrome, 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 syndrome, risk factors were more commonly present before delivery than in those participants who were not diagnosed 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 rst cardiovascular 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 complications. 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 experiencing complications during labor and birth is responsible for creating a supportive environment that provides complex 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 reassuring 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 outcome. When the fetus is not in a favorable lie, the labor process may lengthened, require instrumentation assistance, 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 complicated 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 considerations 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 specic to the woman experiencing a complication during the intrapartal period refer to specic problems and often relate to the broad concepts of fear, anxiety, coping, and fatigue. Examples of possible nursing diagnoses are presented in Box 14-1. The nurse has the unique opportunity to empower the woman and assist her in taking control as much as possible in these difcult 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 instrumental 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

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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 Decient 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, Decit, 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

frequently during the rst stage of labor (cervical dilation and effacement) than during the second stage (maternal expulsive efforts). Nulliparous women have a higher incidence of abnormalities than do multiparous women. Dysfunctional 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 general types of labor dysfunction: hypertonic and hypotonic (Fig. 14-1). These contraction patterns are classied according to when they occur in labor and the nature of the uterine contractions.

HYPERTONIC LABOR
Hypertonic labor contractions are strong and often painful 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 catecholamines. 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 contractions 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),

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

Dystocia
Dystocia, dened as a long, difcult 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, macrosomia and multiple gestation. Also, maternal psychological responses to the labor, based on past experiences, cultural inuences, 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.

Box 14-2 Factors Associated with an Increased Risk for Uterine Dystocia
Uterine abnormalities, such as congenital malformations and overdistention (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.

DYSFUNCTIONAL LABOR PATTERNS


Dysfunctional labor patterns are deviations from the normal pattern of labor as illustrated by a labor curve assessment tool. (See Chapter 12.) Labor alterations occur more

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mm Hg

A
100 75 50 25 0
mm Hg

5 Minutes

10

Increased resting tone 1 2 3 4 5 Minutes


Infrequent contractions; poor intensity

B
100 75 50 25 0
mm Hg

10

5 Minutes

10

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

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 emotional 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 progression and lead to timely interventions. While frequent checks for cervical dilation are not advisable, this assessment, when performed at proper intervals, provides a strong indicator of labor progression. Along with continued assessment of the contraction pattern, the nurse can use this information to validate the 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 difculties 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 difculty communicating their feelings.

HYPOTONIC LABOR
Hypotonic labor is a more common type of uterine dysfunctional pattern that contributes to poor labor progression. 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 dened 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 insufcient for the progression of cervical 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 macrosomia, 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 pregnancies and is the leading cause of uterine hypotonia. Macrosomia, dened 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 contributes to a larger fetus. Hall and Neubert (2005) dene 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 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 signicantly slow down the progress of labor. Various studies have produced conicting data concerning a clear link between the use of analgesia, anesthesia, and the progress of labor. After administration of epidural anesthesia, some women may experience a longer second stage of labor. The effects of the epidural may make it difcult 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 difcult to document which factors contribute most signicantly to a protracted labor.

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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 vaginal 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 articial 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 BIRTH


Contrary to both hypertonic and hypotonic labor, precipitate labor contractions produce very rapid, intense contractions. By denition, 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 rst stage of labor with little or no pain and may present 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 dened 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 rupture 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 hemorrhage related to the rapid birth (Cunningham et al., 2005).
Nursing Considerations

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 relaxation 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 experience can be frightening. The woman may also have concerns regarding a loss of control over her labor. Continuous surveillance, 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 supported 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 postpartum period, the woman must be continuously monitored for hemorrhage. Providing ongoing information and support 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 ndings to the physician or certied 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 ndings.

Initial assessments are paramount to establishing the pattern of precipitous labor. A multiparous patient with a previous history of rapid labors needs to alert her physician or certied nurse midwife (CNM) as soon as she recognizes any signs of labor. Her prenatal record should include this information and be readily accessible to nursing personnel managing her care. In a nulliparous patient, careful examination for cervical dilation and effacement is

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PELVIC STRUCTURE ALTERATIONS


Pelvic Dystocia

Obstetric Interventions
AMNIOINFUSION
Pregnancy outcome in patients experiencing variable fetal heart rate (FHR) decelerations caused by cord compression 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 uid volume in patients with oligohydramnios due to uteroplacental insufciency, premature rupture of the membranes, and postmaturity; it may also be done to dilute meconiumstained amniotic uid (Fraser et al., 2005). Risks of the procedure include infection, overdistention of the uterus, and increased uterine tone.

Pelvic dystocia occurs when contractures of the pelvic diameters 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, neoplasms, congenital abnormalities, traumatic spinal injury, or spinal disorders. In addition, immaturity of the pelvis may predispose some adolescent mothers to pelvic dystocia. During labor, contractures of the inlet, midplane, or outlet can cause interference in engagement and fetal descent, necessitating cesarean birth (Cunningham et al., 2005).
Soft Tissue Dystocia

Soft 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 broid tumors (leiomyomas), ovarian 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).

Nursing Insight Understanding amnioinfusion


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

TRIAL OF LABOR
A trial of labor (TOL) is the surveillance of a woman and her fetus for a set amount of time (usually 4 to 6 hours) during 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 (lowsegment transverse) cesarean birth. Before the TOL, an assessment of the adequacy of the maternal pelvis for vaginal 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

In most circumstances, the uid is instilled through an intrauterine pressure catheter (IUPC); the amniotic membranes must be ruptured for catheter placement. The uid may be warmed with a blood warmer before administration and the infusion may be given by bolus or continuous ow. When possible, a double-lumen IUPC is used because the intrauterine pressure can be monitored without stopping the amnioinfusion. Nursing considerations include careful monitoring of the infusion, the intensity and frequency of uterine contractions, and the maternal vital signs. In some institutions, 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 document the amount of the solution infused and the presence of any vaginal discharge (Gilbert, 2006).

Nursing responsibilities during a TOL include assessment of maternal vital signs and FHR and pattern. If complications arise, the nurse noties 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.

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 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.

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 signicant to the lack of myometrial contractility?

AMNIOTOMY
Amniotomy, or the articial 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

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the lower segment of the fetal membranes; following rupture, the 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 articial 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 contractions 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 immunodeciency virus (HIV) infection (Norwitz, Robinson & Repke, 2002). Optimizing Outcomes Preparing the Patient for an
Amniotomy

and the indication for the amniotomy. The patient may request analgesia or epidural anesthesia before the procedure. If she has not requested any medication, the nurse assists her with relaxation and breathing techniques during 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 articial rupture of membranes. Changes such as transient fetal tachycardia may occur and are common. However, other FHR patterns such as bradycardia and variable 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 notied. Other signs and symptoms of infection include the presence of chills, uterine tenderness on palpation, foul-smelling vaginal discharge, and fetal tachycardia (Simpson, 2005b).

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 assembled: sterile gloves, lubricant, and the Amnihook or Allis clamp. After placing hip pads under the buttocks to absorb the uid, the nurse positions the woman on a padded bedpan 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.

Pharmacological Induction of Labor


INDICATIONS FOR INDUCTION
Induction of labor describes the use of chemical or mechanical modalities to initiate uterine contractions (before their spontaneous onset) to bring about childbirth. 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 monitoring, epidural anesthesia, and a longer stay in the labor unit. Martin et al. (2005) reported that since the year 1989, when data were 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 Pacic 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

Immediately after the articial rupture, the nurse notes and records the FHR and pattern. The color, odor, consistency, and clarity (and amount, if unusual) of the amniotic uid are also documented, along with the time of rupture

Amniotic membrane

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

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Since induction carries certain risks, it is not performed 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 combined 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 dilation, effacement, station, consistency, and position (Table 14-1). In general, labor induction is more likely to be successful 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 Agents

If it is determined that the cervix is not favorable for oxytocin 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 benecial 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 misoprostol to be an effective agent for cervical ripening and induction of labor that also decreases the amount of oxytocin required. Culver et al. (2004) concurred that misoprostol 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 hyperstimulation 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. Table 14-1 The Bishop Score
Score
0 1 2 3

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 oxytocin can be initiated 30 to 60 minutes after removal of the Cervidil insert. When using Prepidil gel, oxytocin induction 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 hyperstimulation occurs. Dinoprostone is FDA approved for cervical ripening. Contraindications to the PGE1 and PGE2 cervical ripening agents include the presence of a non-reassuring FHR pattern, maternal fever, infection, vaginal bleeding, hypersensitivity, regular, progressive uterine contractions, 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 cardiovascular disorders. After insertion, the nurse should clearly document all assessment ndings and administration procedures.
Mechanical Methods

Mechanical methods provide another approach to cervical ripening. Dilators placed in the cervix cause cervical ripening by stimulating the release of endogenous prostaglandins. 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 nger into the cervical os to gently strip the membranes) can be also be used to ripen the cervix.
Oxytocin

Dilation (cm) Effacement (%) Station (cm) Cervical consistency Cervix position

0 030 3 Firm Posterior

12 4050 2 Medium Midposition

34 6070 1 Soft Anterior

5 80 1, 2

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

Oxytocin, 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. Administration 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 induction or augmentation. The dose is increased 1 to 2 milliunits 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).

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Table 14-2 Cervical Ripening Agents


Medication Prostaglandin E1 Misoprostol (Cytotec) Prostaglandin E2 Dinoprostone (Cervidil Insert, Prepidil Gel) May stimulate labor contractions Promotes initiation of cervical ripening Action Induces labor contractions Adverse Effects Diarrhea, abdominal pain, headaches, fever, tachysystole, uterine hyperstimulation Uterine hyperstimulation, fever, back pain, headache, nausea and vomiting, diarrhea, hypotension, tachysystole Adverse effects are more common with intracervical administration. Dosage Intravaginally: 25 mcgrepeat every 46 hours until Bishop score equals 8 or greater. 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.
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).

Optimizing Outcomes Through the safe


administration of oxytocin

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

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 sidelying or upright position. Assessment of the patient and fetus is conducted and documented. The solution is prepared and administered with a pump delivery system according to the prescribed orders. The piggyback solution is connected to the intravenous infusion at the port nearest the point of venous insertion. The medication is administered as ordered; ongoing assessments are conducted 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 reactions (FHR and pattern, maternal vital signs, pattern and

Oxytocin acts on receptors in the myometrium to create 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 hyperstimulation 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)

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Higher doses are associated with an increased incidence 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 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 number of restrictions to its use.

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 scientic research and validation of their effectiveness. Much of the information about how they work is anecdotal, which also makes it difcult to evaluate the risks and the benets, critical information for patients and their health care providers (Tenore, 2003). Nonherbal methods include acupuncture, the ingestion of a laxative (e.g., castor oil), and the stripping of membranes.

clinical alert
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 surgery Conditions 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

NURSING CONSIDERATIONS
The nurses responsibilities during labor induction or augmentation 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 protocols 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 ow sheet in the patient record: Patients vital signs (blood pressure, pulse and respirations 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 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 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 institutional protocol; positioning the patient on her side; increasing the

Augmentation of labor is used to stimulate uterine contractions after labor has begun spontaneously but is not progressing satisfactorily. It is most commonly indicated for the management of hypotonic uterine dysfunction. Labor augmentation may be accomplished with amniotomy, oxytocin infusion, and nipple stimulation. 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 augmentation 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 contraction. A breast pump may also be used. Nipple stimulation rarely causes hyperstimulation of the uterus. However, the results of nipple stimulation are less predictable than the administration of specied 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 evidencebased research before their endorsement as viable alternatives for labor induction.

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

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The nurse needs to discuss pain relief options with the patient before oxytocin administration. The information presented should include prescribed medications 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 induction 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 condence.
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 ow sheet during labor induction with oxytocin?

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 procedure 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 application to achieve pelvic relaxation and decrease pain. An episiotomy is usually performed to prevent perineal tearing. 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 compression 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.

INSTRUMENTATION ASSISTANCE OF BIRTH


Forceps 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. Speculation as to the reason for this trend has been attributed to a fear of malpractice related to complications associated with the methods as well as a lack of physicians training in the use of delivery instrumentation (Patel & Murphy, 2004).
Forceps-Assisted Birth

A 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 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 midline 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 following reasons: dystocia; an inability to push with contractions (e.g., due to exhaustion, spinal or epidural anesthesia, spinal cord injury); to prevent worsening of serious

Perineal trauma is one of the major complications associated 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 rst postbirth voiding. Some women have reported fecal incontinence following forceps injury. Women who experience forcepsrelated 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. Supercial scalp and facial markings are the most common complications and are rarely signicant. However, it is important for the nurse to clearly discuss this possibility with the family. Once the parents understand that the trauma marks gradually disappear, they are usually more accepting of the babys (usually) supercial injuries. Other forceps-related complications that rarely occur include facial nerve injury, cephalhematoma, retinal hemorrhage, and ocular trauma. Neonatal intracranial bleeding constitutes a major concern but it is often difcult to ascertain whether the hemorrhage resulted from the forceps or it was related to the difcult birth (Belfort, 2003).

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Handle

Fenestrated blades Shank

Solid blades

Shank

Handle

Lock

Simpson forceps (outlet) Fenestrated blades Shank Handle

Tucker-McLean forceps (outlet)

Piper forceps (aftercoming head in breech)

Direction of gentle traction for outlet forceps delivery

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

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 Birth

Vacuum-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 plastic cup that is attached to the fetal head over the posterior fontanel and a suction apparatus that uses negative pressure to facilitate the birth of the head. This modality is used for a patient who is unable to voluntarily push during the second stage of labor (most often due to exhaustion 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 pressure 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 sufcient 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 vacuum gun and the pressure and is responsible for all of the required documentation. The perinatal team must communicate frequently during the procedure as they each assess progress or the lack of progress. The nurse, following protocols, can advocate for cesarean birth if maternal exhaustion and/or failure of descent indicates that the

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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 intensive care unit for hemodynamic monitoring. Maternal vital signs, FHR, urine output, deep tendon reexes, 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 betamethasone 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 Considerations
B

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.

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 nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The nurse plans and evaluates all interventions on a continuous basis. The patient with severe preeclampsia is in an extremely fragile condition. Since any change in condition may require an emergency intervention, the nurse must be prepared to provide the necessary care immediately. The nurse is responsible for the continuous monitoring of several key parameters (Box 14-4). Laboratory tests include a complete blood count (CBC) with platelets, coagulation prole to assess for disseminated intravascular coagulation (DIC), metabolic studies for determination of liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], lactate dehydrogenase [LDH]) and electrolyte studies to establish renal functioning (ACOG, 2002). (See Chapter 11 for further discussion.)

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 lacerations, and subdural hematoma. The infant should be carefully observed for signs of trauma and infection at the application site.

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 quadrant 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

Maternal Conditions that Complicate Childbirth


HYPERTENSIVE DISORDERS
Management 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

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Box 14-4 Intrapartal Nursing Care for Patients with Preeclampsia


BLOOD PRESSURE The 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 ADMINISTRATION Administer medication as ordered and evaluate its effect. Adhere to hospital protocol for magnesium sulfate infusion. Monitor maternal vital signs, FHR, urine output, DTRs, IV ow rate and serum magnesium levels to assess for magnesium sulfate toxicity (e.g., depressed respirations, hyporeexia, 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 BALANCE Edema 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 notied. A dipstick measurement 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 STATUS Deep tendon reexes (DTRs) are assessed every 4 hours (or more frequently) and rated on a scale of 1 to 4. Reexes greater than 2 are a sign of worsening status. If dorsiexion of the foot produces clonus (convulsive spasm), this nding provides an additional indication of a deteriorating maternal condition. PULMONARY STATUS Auscultation 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 STATUS Assess 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 SYMPTOMS Headaches, blurred vision, severe right upper quadrant epigastric pain, and restlessness are all indicators of impending eclampsia. Prepare for immediate delivery. SEIZURES Protect the patient. Keep the airway patent: turn head to one side and place pillow or folded linen under one shoulder or back. Call for assistance. Ensure that the siderails have been raised. Observe and document all seizure activity. Notify the physician and prepare for delivery. Administer oxygen. FETAL STATUS Monitor 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 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. Providing ongoing information to the patient and her family is an essential nursing intervention to help decrease anxiety and fear (Sibai et al., 2005).

DIABETES
Women 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 successful, 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 parameters 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 dened as weight 4500 g) or fetal growth restriction are all indications for elective preterm 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 performed to conrm fetal lung maturity. Fetal lung maturation is better predicted by an amniotic uid phosphatidylglycerol level of greater than 3% than by an amniotic uid lecithin/sphingomyelin ratio (3:1) in the pregnancy complicated 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 pregestational diabetes centers on the close surveillance of maternal hydration and blood glucose levels to prevent complications associated with dehydration, hypoglycemia, and hyperglycemia. An intravenous infusion of a maintenance 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 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 hyperglycemia during the intrapartal period be avoided to prevent neonatal metabolic problems such as hypoglycemia.

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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 maternal fetal 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 neonatologist, 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 glycemic 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 hypoglycemia 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 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.

PRETERM LABOR AND BIRTH


Preterm 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 gure is the highest number recorded since preterm birth data have been collected. Accompanying this dramatic increase in preterm births is a 50% increase in premature infants born with neurological decits (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).

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) during the postpartal period. Hemorrhage is more likely if the uterus was overdistended due to fetal macrosomia or hydramnios. (See Chapter 16.)

The causes for preterm birth are often a series of overlapping conditions such as premature rupture of membranes combined with cervical incompetence. Canavan, Simhan, and Cartis (2004) reported that premature rupture 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 effacement 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 possibility of subdural or intraventricular hemorrhage.
Nursing Considerations

The nurse should encourage mothers with pregestational 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 maintaining a healthy weight and undergoing glucose testing during routine health maintenance visits.

In addition to careful maternal monitoring, FHR monitoring is one of the most important nursing responsibilities when caring for a patient in preterm labor. A number of perinatal complications such as preeclampsia, intraamniotic infection, oligohydramnios, umbilical cord compression, placental abruption, intrauterine growth restriction, uteroplacental insufciency, 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 neurological decits 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 correct 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

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unit four The Birth Experience 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?

monitor each fetus. The tocodynamometer needs to be placed at the height of fundus to ensure the best interpretation of the labor contractions (Simpson, 2004). Optimizing Outcomes Providing pain relief during
preterm labor and birth

The length of the rst stage of labor for a woman who is preterm 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 difculty 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.

Complications of Labor and Birth Associated with the Fetus


FETAL MALPRESENTATION
Fetal 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 presentation, in which the buttocks or legs present rst, occurs in approximately 3% of all births and is considered the most common malpresentation. (See Chapter 12.) It is important that these conditions be identied during the antepartum 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 conrmed by ultrasonography. During labor, descent of the fetus in a breech presentation 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).

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 psychological status can help direct the care. Expressions of caring coupled with dialog that includes specic 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.

Nursing Insight Breech presentation and


meconium in the amniotic uid
When the fetus is in a breech presentation, the presence of meconium in the amniotic 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 indicative of fetal hypoxia. When the fetus is in a breech position, the FHR is best auscultated at or above the maternal umbilicus.

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 problem. 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 educational offerings that focus on heightening cultural sensitivity.

During the vaginal birth of a fetus in a breech presentation, the physician uses labor mechanisms that manipulate 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 estimated to be larger than 3800 g or smaller than 1500 g; the labor is ineffective; this is the womans 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

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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), macrosomia, CPD, and contractures of the maternal pelvis. Vaginal birth may be accomplished if the fetus exes to a vertex presentation. 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).

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

uterine anomalies, CPD, placenta previa, multifetal gestation, and oligohydramnios (Cunningham et al., 2005). Before the version, ultrasonography is obtained to conrm the fetal position, locate the umbilical cord; rule out placenta previa; assess the maternal pelvic dimensions and the amniotic uid volume, fetal size and gestational age, and the presence of anomalies. Before the version, a non-stress test (NST) is performed to conrm fetal wellbeing, 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 buttocks to rotate the position. Complications associated with version include umbilical cord compression, placental 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 successful 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, administering medications as ordered, and conducting constant surveillance of the maternalinfant dyad. The patient

An 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,

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Intravenous tocolytic drug

Figure 14-6 External cephalic version is a maneuver performed through the maternal abdominal wall in an attempt to change the fetal position from a breech to a cephalic presentation. needs to know not only that the version attempt might not be successful; she must also be aware of the associated complications that may occur such as rupture of the membranes, fetal bradycardia, and discomfort. During the version, if there is any indication of signicant 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 Version

With 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). Internal 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 performed for malpresentation in multiple gestations. Nursing responsibilities center on maternalfetal monitoring and providing support to the woman.

SHOULDER DYSTOCIA
Shoulder dystocia is an uncommon obstetric emergency that occurs in 0.5% to 1.5% of all births (Jevitt, 2005). In this type of dystocia, the head is born but the anterior shoulder cannot pass under the maternal pubic arch. The problem is often not identied until the head is born. Risk factors for shoulder dystocia include maternal pelvic abnormalities, a history of shoulder dystocia in a previous pregnancy, obesity, diabetes, prolonged labor, postdate pregnancy, and fetal macrosomia (greater than 4000 g) (Gherman, 2005). Although there are no methods to predict or prevent shoulder dystocia, the nurse should be alert to clinical

indicators: slowed labor progression and formation of a caput succedaneum that increases in size. When the fetal head emerges on the perineum (crowning), it retracts instead of protruding with subsequent contractions (termed the turtle sign), and external rotation does not occur (ACOG, 2002b; Bowes & Thorp, 2004; Jevitt, 2005). Fetal/neonatal injuries are related to birth asphyxia; damage to the brachial plexus; and fractures, usually of the humerus or clavicle. Maternal injury is most commonly associated with excessive blood loss that results from uterine atony or rupture; other risks include lacerations, extension of the episiotomy, and postpartum endometritis. A number of maneuvers have been attempted to free up the anterior shoulder and facilitate delivery. The McRoberts maneuver is one approach. The woman is placed in a dorsal lithotomy position, and her thighs are sharply exed on her abdomen. This position increases the angle between the symphysis pubis and the sacral promontory, allowing for greater room in fetal descent. Suprapubic pressure applied immediately above the symphysis pubis may be needed along with the McRoberts maneuver to loosen the trapped shoulders (Baxley & Gobbo, 2004; Camune & Brucker, 2007) (Fig. 14-7). Other methods of delivery assistance for shoulder dystocia center on maternal positional changes: a hands-andknees position, a squatting position, or a lateral recumbent position (Bowes & Thorp, 2004; Camune & Brucker, 2007; Jevitt, 2005). Optimizing Outcomes When birth is complicated
by shoulder dystocia

When childbirth is complicated by shoulder dystocia, the nurses role is to assist the woman in assuming the positions, assist the physician with the maneuvers, and to document all procedures. The nurse also provides careful

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labor is suggested if the woman is nulliparous. Women with a previous history of cesarean birth for CPD may also be offered a trial of labor although a prompt cesarean birth is recommended at the earliest sign of maternal or fetal compromise. The maternal pelvis is assessed before the onset of labor to determine type and size. A gynecoid pelvis is considered to be the most common female pelvic type and most amenable to vaginal birth although markedly small dimensions may preclude a vaginal birth. Other pelvic types are the android, anthropoid, and platypelloid. (See Chapter 5 for further discussion.) Although the other types of pelvises may not contraindicate a trial of labor, vaginal birth may not be possible for the woman with a platypelloid pelvis because its markedly shortened anteriorposterior diameter prevents fetal descent (Cunningham et al., 2005).
Nursing Care

Figure 14-7 Methods to relieve shoulder dystocia. A. Pressure is applied immediately above the maternal symphysis pubis to push the fetal anterior shoulder downward. B. McRoberts maneuver. The womans thighs are sharply exed on her abdomen to straighten the pelvic curve. C. Angle of pelvis before maneuver. D. Angle of pelvis after maneuver. instruction to the patient to facilitate cooperation and understanding (Jevitt, 2005). After birth, the woman is closely observed for signs of hemorrhage and soft tissue trauma of the birth canal; the neonate is assessed for fracture of the clavicle or humerus, brachial plexus injuries, and asphyxia (Bowes & Thorp, 2004).

A thorough nursing assessment including a review of present and past pregnancies is important in guiding care. Women with a history of cephalopelvic disproportion are at increased risk during the present labor. Slow progression of effacement and dilation, lack of fetal descent, and excessive pain are all possible indicators of CPD. Nursing interventions such as maternal position changes, particularly to an upright posture (e.g., sitting or squatting) to widen the pelvic girdle, relaxation, and water therapy are strategies to facilitate labor progression. The use of analgesic agents may alleviate pain-creating tension that is interfering with fetal descent. Supportive care includes information related to labor status and encouragement when progress has been made.

MULTIPLE GESTATION
Managing the births of more than one fetus is complex and requires the expert collaboration of medical and nursing personnel. The gestational age, number, health and presentation of the fetuses determine the mode of birth, whether vaginal or cesarean.

Nursing Insight Fetal presentations with


multiple gestations
Both fetuses present in the vertex position (most favorable for vaginal birth) in only one half of all twin pregnancies. In one third of multifetal pregnancies, one twin may present in the vertex position and one in the breech position (Cunningham et al., 2005).

CEPHALOPELVIC DISPROPORTION
Although there are true problems that create issues between the head of the fetus and the pelvis of the mother, in the United States, cephalopelvic disproportion (CPD) is often used to describe unsuccessful attempts at vaginal birth. When CPD is present, the fetus cannot t through the maternal pelvis to allow a vaginal birth. Often related to excessive fetal size (macrosomia), CPD occurred at a rate of 14.6 per 1000 live births in 2003 (Martin et al., 2005). A macrosomic infant (birth weight greater than 4000 grams) is likely to have a large head that can prevent descent into the mothers pelvis. Despite ultrasound evaluation, it is difcult to predict the safest mode of birth for the macrosomic infant. A trial of

Multiple births are associated with more complications than singleton births. The womans health status may be compromised by problems such as hypertension of pregnancy, anemia, or gestational diabetes. She is also at increased risk for hemorrhage related to atony from uterine overdistention, abruptio placentae, and multiple or adherent placentas. Because of the multiple fetuses, abnormal fetal presentation may occur. Increased fetal/newborn complications are related primarily to problems associated with low-birth-weight infants due to preterm birth and intrauterine growth restriction. Intrapartal fetal distress may result from cord prolapse and the onset of placental

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unit four The Birth Experience onset of labor. Epidural anesthesia is considered a safe method for providing relief of pain and it allows prompt intervention in case the second twin requires an external version or a cesarean birth (Vadhera & Locksmith, 2004). The woman may experience an unmedicated birth provided she understands that if it is necessary to proceed to a cesarean birth she will receive a general anesthetic to facilitate uterine relaxation.

separation after the birth of the rst fetus. Because of these problems, the risk for long-term disabilities such as cerebral palsy is greater among multiple births. Women who present at 38 weeks with a twin pregnancy are less likely to experience fetal morbidity and mortality and may be appropriate candidates for a vaginal birth. It is recommended, although it is not always possible, that women with a multiple gestation, particularly triplets or higher-order multiples, deliver at a tertiary care center where facilities are available in the event of an emergency. Birthing centers must have transport ready for infant transfer to neonatal intensive care units. Patients who will undergo labor or a trial of labor require careful monitoring. Ultrasound is used to determine position and presentation of the fetal parts. Electronic fetal monitoring (EFM) is applied. It is important to identify each of the individual FHRs and the use of a separate monitor for each fetus is preferable. Interventions, such as analgesia, anesthesia, and intravenous infusions are determined on a case-by-case basis. The stimulation of labor with oxytocin, and epidural anesthesia, forceps, and vacuum assistance and fetal version may all be used to facilitate the vaginal birth of twins. Women in good health and with no evidence of fetal distress should be given the opportunity to participate in medical decision management. When the woman is fully dilated and ready to push, she is moved to the birthing suite, where personnel, equipment, and supplies are readily available in the event there is a need for a cesarean birth. The woman may safely give birth in a labor, delivery, recovery, postpartum (LDRP) suite provided there is quick access to the surgical area. The nurse prepares the woman and her support for the possibility that she may experience both a vaginal and a cesarean birth depending on the fetal presentation. The nurse also explains the external version procedure in case this intervention is necessary. Patient education is carried out in a timely manner when the patient is capable of participation. The majority (approximately 80%) of vertex, vertex twins are delivered with success vaginally. The rst infant born is identied as A and neonatal care is initiated. Oxytocin, usually given to halt contractions and minimize bleeding, is withheld to avoid compromising circulation to the unborn fetus. In the vertex, breech presentation, an external version of the second twin is attempted provided that the conditions are favorable. If the second fetus is a footling breech, has a hyperextended head, or exhibits signs of compromise, a cesarean birth is considered the better option. The birth of the second twin normally occurs within 15 minutes of the birth of the rst twin. Although there has been concern over complications associated with a longer time period between births, studies have shown that with proper fetal monitoring and maternal surveillance, a safe vaginal birth can take place in an indenite amount of time (Cunningham et al., 2005; Vadhera & Locksmith, 2004). The nurse documents the time of birth for the rst infant and all subsequent infants who are born.

There is controversy over the medical management in twin births where the second twin is not in a vertex position. Data from a retrospective cohort study with 15,185 participants that studied twin births of vertex, nonvertex pairs showed that there is a higher risk of neonatal mortality and morbidity with vaginal birth of the nonvertex twin (Yang et al., 2005). The acknowledged limitations of large cohort studies lies in the fact that they are chart reviews and therefore do not examine complications associated with the birth of the second twin (Wen et al., 2004). Triplets and higher order multiples generally require a cesarean birth. This mode of birth decreases the risk that the second fetus will experience anoxia as well as other complications such as cord entanglement and premature placental separation. While there are reports of triplet vaginal births, these successes are tempered with the strong possibility that both the second and the third neonates may be in breech presentations and require operative interventions. If it is deemed possible for the woman to give birth to triplets vaginally, the medical team must be on ready standby for an immediate cesarean surgery (Cunningham et al., 2005).
Now Can You Discuss birth options for a woman with a
multiple gestation? 1. Identify what factors determine whether a woman with multiple gestation may be allowed to attempt a vaginal birth? 2. Describe the primary recommendations concerning the childbirth options available for a woman with a multiple gestation? 3. Discuss controversies that surround the medical management of twin births?

NON-REASSURING FHR PATTERNS


Fetal heart monitoring is one type of assessment that provides the nurse, the patient, and her support(s) feedback concerning the well-being of the fetus. Families often request to increase the volume of the fetal monitor so that they hear the reassurance of a strong heartbeat. It is essential that the nurse understand actions that should be taken when decelerations or other ominous FHR patterns are detected. (See Chapter 12.) Optimizing Outcomes Responding to a nonreassuring FHR pattern

Across Care Settings: Planning the multiple


gestation birth
Together, the obstetrician, anesthesiologist, and patient discuss the anesthetic options available for childbirth. This collaborative meeting is best done in an ofce visit before the

Provide information to the woman; assist her to a lateral position. Encourage relaxation and mental imagery to reduce anxiety.

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Assess for and correct maternal hypotension by elevating the legs. Increase the rate of the maintenance IV uids. Assess for hyperstimulation by palpating the uterus. Discontinue oxytocin if infusing. Administer oxygen at 8-10 L/min by mask. Consider internal monitoring to obtain more accurate fetal/uterine assessments. Apply fetal scalp or acoustic stimulation. Assist with fetal oxygen saturation monitoring if ordered. Assist with birth (cesarean or vaginal-assisted) if a nonreassuring FHR pattern cannot be corrected.

applying pressure with the ngers to the fetal scalp during a vaginal examination. Vibroacoustic stimulation is accomplished by placing an articial larynx or fetal acoustic stimulation device on the maternal abdomen directly over the fetal head for 1 to 2 seconds. Acceleration of the FHR in response to the stimulation is usually indicative of fetal wellbeing; lack of a FHR acceleration does not necessarily indicate fetal compromise but warrants further evaluation.
Fetal Oxygen Saturation Monitoring

It is important that the nurse immediately noties the physician or certied nurse midwife and initiate appropriate interventions for non-reassuring FHR patterns. (See Chapter 12.) A prolonged deceleration is the presence of a decrease in the FHR below the baseline 15 beats per minute or more that lasts more than 2 minutes, but less than 10 minutes. A deceleration that lasts more than 10 minutes is considered a baseline change (National Institute of Child Health and Human Development [NICHD], 1997). Benign causes of prolonged FHR decelerations include pelvic examination, application of a fetal spiral electrode, rapid fetal descent, and prolonged maternal Valsalva maneuver. Less benign causes include progressive severe variable decelerations, umbilical cord prolapse, hypotension associated with spinal or epidural analgesia/anesthesia, paracervical anesthesia, tetanic uterine contractions, placental hemorrhage, uterine rupture, and maternal hypoxia. A prolonged FHR deceleration that occurs late in the course of severe variable decelerations or a series of prolonged decelerations may occur immediately before fetal death.

Fetal pulse oximetry (FPO), or continuous monitoring of fetal oxygen saturation, is similar to pulse oximetry used in children and adults. A small sensor designed to assess oxygen saturation is inserted next to the fetal cheek or temple area. The sensor is connected to a monitor; incoming data are continuously displayed on the uterine activity panel of the fetal monitor tracing. The normal range for oxygen saturation in the healthy fetus is 30% to 70%. Before this modality can be used, certain criteria (e.g., 36 weeks gestation or greater; singleton fetus; vertex presentation; non-reassuring FHR pattern; ruptured membranes; fetal station less than or equal to 2) must be met. The American College of Obstetricians and Gynecologists (ACOG) has not endorsed FPO in clinical practice and recommends further clinical research for this assessment modality (ACOG, 2005).
Fetal Scalp Blood Sampling

critical nursing action Assisting with Intrauterine Resuscitation


Intrauterine resuscitation, a term used to describe interventions initiated when a non-reassuring FHR pattern is detected, centers on improving uterine and intervillous space blood ow and cardiac output (Simpson & James, 2005). When intrauterine resuscitation is underway, nursing priorities are: (1) to open the maternal and fetal vascular systems; (2) to increase the blood volume; and (3) to optimize oxygenation of the circulating blood volume. These interventions are accomplished by maternal positional changes, increasing the rate of the primary IV, and providing oxygen by face mask.

Fetal scalp blood sampling is conducted to assess the fetal pH, PO2 and PCO2. A small sample of capillary blood is taken from the fetal scalp as it presents at the dilated cervix. If the fetus is hypoxic, there is a drop in the pH (acidosis). A scalp blood pH greater than 7.25 is considered normal for a fetus during labor; a scalp blood pH below 7.20 is acidotic and is recognized as an indicator of fetal distress. However, because of the frequent variations in fetal blood gas values associated with transient circulatory changes, fetal blood sampling is rarely performed except in tertiary centers that have a capability for repetitive sampling and the rapid report of results. Depending on the situation, watchful waiting with continuous monitoring conducted by the nurse may provide the best option for assessment of fetal well-being. Since nonreassuring FHR patterns constitute a risk indicator for cesarean birth, the nurse and all members of the health care team must be ready for this outcome at all times. It is important to provide ongoing support for the laboring woman and keep her informed of her labor progress and fetal status. When a non-reassuring FHR pattern is detected via electronic monitoring
When electronic monitoring reveals a non-reassuring FHR pattern, the nurse needs to maintain a calming presence and offer factual, simple explanations for all actions. For example, the nurse may say: We are concerned about your babys heart rate pattern. I am going to change your position to your side to increase oxygen ow to your baby. I am also going to place this oxygen mask on your face to increase the oxygen ow to you and to your baby, and increase your IV rate. Do you have any questions? I am here to help in any way and I will stay here with you. Please let me know what concerns you have.

When non-reassuring FHR patterns are detected by EFM, other methods of assessment may be initiated: Fetal scalp and vibroacoustic stimulation Fetal oxygen saturation monitoring Fetal scalp blood sampling
Fetal Scalp and Vibroacoustic Stimulation

Fetal stimulation is done to elicit an acceleration of the FHR (15 beats per minute for at least 15 seconds) that occurs in response to a tactile stimulus (Tucker, 2004). Acceleration of the FHR will not occur in the presence of fetal distress and acidosis; thus, fetal stimulation is an assessment of the fetal acidbase balance. Scalp stimulation is conducted by

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Amniotic Fluid Complications


Oligohydramnios (less than 300 mL of amniotic uid), hydramnios (polyhydramnios) (greater than 2 L of amniotic uid), and the presence of meconium (the rst stools of the infant) in the amniotic uid complicate labor and birth.

Optimizing Outcomes Intrapartal neonatal


suctioning and meconium-stained amniotic uid

OLIGOHYDRAMNIOS
Oligohydramnios may result from fetal renal abnormalities, poor placental perfusion, or premature rupture of the membranes. During labor, the absence of the amniotic uid buffer may lead to cord compression during contractions and decreased fetal blood ow as evidenced by variable heart rate decelerations. Women with pregnancies complicated by oligohydramnios require careful nursing and medical surveillance; amnioinfusion may be indicated to replace the cushion of uid for the cord and relieve the frequency and intensity of variable decelerations. (See Chapter 12.)

The nasopharynx and oropharynx of the neonate born in the presence of meconium-stained amniotic uid are often suctioned before the rst breath to reduce the incidence and severity of meconium aspiration syndrome (MAS). However, because research does not support the efcacy of routine intrapartum suctioning to prevent MAS, this practice is no longer recommended (Vain et al., 2004).

NUCHAL CORD
Nuchal cord (a cord that is wrapped around the infants neck) and cords with true knots are observed in approximately 1% of all births. Nuchal cord, which rarely causes hypoxia, occurs most often in fetuses with long umbilical cords. When a tight knot is present in the cord, variable heart rate decelerations associated with fetal asphyxia may be noted on EFM. Nursing interventions follow protocols used for other abnormal variations of the fetal heart tracing. Once the head is born, gentle palpation is used to feel for the cord. If the cord is present, it is loosened and carefully slipped over the head. If it is too tightly coiled to allow this intervention, the cord is clamped twice, cut between the clamps, and unwound from around the neck before the shoulders are delivered. Otherwise, the cord could tear and interfere with the fetal oxygen supply.

HYDRAMNIOS
Hydramnios occurs in multiple gestations, fetal anomalies, and as a complication of maternal disease such as diabetes. During labor, the nurse needs to be aware that the excessive volume of uid may obscure the fetal heart tracings. Hydramnios can cause fetal malpresentation because of the extra uterine space for the fetus to turn that it provides. The mother is also at risk for prolapse of the umbilical cord because the increased amount of uid pushes the fetus high into the uterine cavity. Preterm rupture of the membranes, another complication associated with hydramnios, increases the risks of both infection and prolapsed cord.

Complications Associated with the Placenta


Critical nursing actions are required when the womans intrapartum course is complicated by bleeding related to placenta previa (a low implantation of the placenta) or abruptio placentae (a premature separation of the placenta). (See Chapter 11.) Either condition places the woman at risk for hemorrhage and shock. A deteriorating physiological status of the mother impacts the fetus and often results in hypoxia. The nurse faces the challenge of helping to manage this intrapartum emergency. Guidelines for nursing care of the patient experiencing an intrapartal hemorrhage are presented in Table 14-3.

MECONIUM
Meconium-stained amniotic uid during intrapartum is an indication for careful fetal surveillance by EFM and possibly fetal scalp blood sampling. Although not always a sign of fetal distress, its presence, which occurs during fetal loss of sphincter control, is highly correlated with its occurrence. Reasons for the passage of meconium during labor include: Hypoxia-related peristalsis and sphincter relaxation Breech presentation or normal physiological function that occurs with fetal maturity Following umbilical cord compression-induced vagal stimulation in the mature fetus Meconium staining, which occurs in approximately 20% of births, is observed more frequently in prolonged pregnancies. A decrease in amniotic uid (oligohydramnios) increases the viscosity of the meconium and the risk of neonatal aspiration during delivery. The nurse must carefully document the presence of meconium stained uid at the time of rupture of the membranes. In addition, the nurse should note the occurrence of variable decelerations and immediately notify the physician or certied nurse midwife regardless of whether or not meconium is present. Amnioinfusion has been shown to be effective in decreasing the fetal mortality associated with variable FHR decelerations.

PLACENTA PREVIA
With placenta previa, bleeding occurs when the lower uterine segment begins to differentiate from the upper segment late in pregnancy and the cervix begins to dilate. If the bleeding has stopped, the maternal vital signs are stable, the fetal heart sounds are of good quality, and the fetus has not yet reached 36 weeks, the woman is usually managed by expectant watching. If the woman is at term (greater than 37 weeks of gestation) and in labor or bleeding persistently, immediate birth by cesarean is almost always indicated. Women diagnosed with partial or marginal placenta previa who have no bleeding or minimal bleeding may be allowed to attempt a vaginal birth. When cesarean birth is planned, nursing responsibilities include continuous maternalfetal assessment while preparing the woman for surgery. Maternal vital signs are

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Table 14-3 Care of the Patient Experiencing an Intrapartal Hemorrhage


Assessment Vital Signs Plan Establish maternal stability. Intervention Take every 5 minutes if unstable, or every 15 minutes if stable. Use pulse oximetry. Auscultate respirations. Evaluation Vital signs are within normal range. Pulse is between 60 and 120 beats/ min. Respirations are between 14 and 26 breaths/min. Temperature is less than 100.4F (38.0C). Blood pressure is greater than 90/60. Bleeding Resolve hemorrhage. Prevent shock. Start two large-bore IV sites. Infuse normal saline and lactated Ringers solution. Estimate blood loss (1 g 1 mL) for replacement. Infuse blood products as necessary. Monitor circulatory volume using CVP/ Swan-Ganz catheter as needed for extreme bleeding. Send blood sample to lab for analysis of gases. Document blood loss. Intake/Output Prevent volume depletion. Insert indwelling urinary catheter. Measure and record output every hour. Measure and record input every hour. Fetal Status Prevent fetal injury. Continuous electronic fetal monitoring Fetal heart rate tracings remain between 120 and 160 beats/min. No evidence of abnormal tracings. Patient verbalizes an understanding of her condition. Face displays no grimace. Muscles remain relaxed. Urine output will be greater than 30 mL/hr. Bleeding is minimized. Homeostasis is established.

Emotional Response

Assist patient to cope with condition.

Educate the patient regarding all procedures. Inform the patient of her status throughout the bleeding crisis. Provide relaxation and breathing techniques. Provide spiritual support as necessary.

Pain

Reduce pain.

Provide relaxation and breathing techniques. Use guided imagery. Offer massage. Monitor contractions. Offer limited pain medication as ordered.

Patient reports pain on a scale of 110 as between 3 and 5.

Adapted from MacMullen et al. (2005); Curran (2003); and Mandeville & Troiano (1999).

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assessed for indicators of hemorrhage (decreasing blood pressure, tachycardia, changes in the level of consciousness (LOC), and oliguria). Continuous EFM is used to assess the fetus for signs of hypoxia. There is an increased risk for postpartal hemorrhage because the placental site is in the lower uterine segment, which does not contract as efciently as the upper segment. Also, because the uterine blood supply is less in the lower uterine segment, the placenta tends to grow larger than when implanted in the upper segment. Thus, a larger denuded surface area is exposed after removal of the placenta. Nursing care throughout the intrapartal course centers on providing emotional support for the woman and her family and collaborating with and supporting medical management.

PLACENTAL ABRUPTION
Placental abruption (abruptio placentae), which tends to occur in late pregnancy, may occur as late as the rst or second stage of labor. Although the primary cause of premature placental separation is unknown, predisposing factors include maternal hypertension, cocaine use (associated with vasoconstriction), direct trauma, and a history or previous placental abruption (Ananth, Oyelese, Yeo, Pradhan, & Vintzileos, 2005). Treatment for abruptio placentae depends on the severity of maternal blood loss and the fetal maturity and status. If the abruption is mild and the fetus is less than 36 weeks and not in distress, expectant management may be implemented. (See Chapter 11.) When the fetus is at term gestation or if the bleeding is moderate to severe and the woman or fetus is in jeopardy, delivery is facilitated. Nursing care includes continuous maternal-fetal monitoring and emotional support. The patient is maintained in a lateral position to prevent pressure on the vena cava and to facilitate placental blood ow. To avoid further damage to the injured placenta, no vaginal or pelvic examinations are performed and no enemas are administered. Blood and uid volume replacement are implemented to maintain the urine output (assessed by indwelling Foley catheter) at 30 mL/hr or more and the hematocrit at 30% or more. Hemodynamic monitoring may be necessary. If the premature placental separation occurs during active labor, the physician may elect to rupture the membranes or augment the labor with intravenous oxytocin to hasten birth. Rupturing the membranes prevents large amounts of blood from collecting in the myometrium, which can interfere with uterine contractions. Articial rupture of the membranes allows a slow, steady escape of amniotic uid, preventing a sudden change in intrauterine pressure that may encourage further placental separation. Vaginal birth is desirable, especially in cases of fetal death. If birth does not appear to be imminent, a cesarean birth is the delivery method of choice. However, cesarean birth should be reserved for cases of fetal distress or other obstetric indications and should not be attempted if the woman has severe and uncorrected coagulopathy (i.e., disseminated intravascular coagulation [DIC]). The patient with unresolved bleeding from a placental abruption is most vulnerable to severe complications. Maternal problems resulting from abruptio placentae include a Couvelaire uterus (the accumulation of blood between the

separated placenta and the uterine wall) and DIC. Although a Couvelaire uterus is rare, its implications are severe. The uterus takes on a bluish tinge as blood extravasates from the clot into the myometrium. Contractility is lost. The condition is so severe that a hysterectomy may be necessary to control the bleeding (Cunningham et al., 2006). If DIC has developed, surgery poses a major maternal risk due to the possibility of hemorrhage during surgery and later from the incisional site. The administration of intravenous brinogen or cryoprecipitate (which contains brinogen) may be given to increase the maternal brinogen level. The maternal prognosis depends on how quickly interventions are initiated and how effective they are in halting the hemorrhage. Death can occur from massive hemorrhage that leads to shock or renal failure from circulatory collapse. The fetal prognosis depends on the extent of the abruption and the severity of the accompanying hypoxia.

case study A Pregnant Adolescent in

the Emergency Department


Maria Selles is a 14-year-old girl who arrives in the emergency department (ED) complaining of severe abdominal pain. She is pale and diaphoretic. A small amount of bright red blood is slowly trickling from her vagina. On assessment, her blood pressure is 120/70; pulse, 100; respirations 22 breaths/minute; temperature 99F (37.2C). Her physical examination reveals an enlarged abdomen, which is rigid and board-like with extreme tenderness. Maria is known to the ED because of a history of repeated drug abuse including cocaine. She has been living on the street since she was kicked out of her house several months ago.

critical thinking questions


1. Based on this initial information, what is the nurses assessment of the possible problem? 2 Since Maria is in such extreme distress, the nurse is aware of a need to limit the number of questions asked. What critical questions should be asked at this point? 3. What laboratory tests would be important to check?
See Suggested Answers to Case Studies in the text on the

Electronic Study Guide or DavisPlus. The nurses further assessment reveals dark red vaginal bleeding and clinical signs consistent with pregnancy (the presence of abdominal enlargement, deeply pigmented areolae, linea nigra, and striae gravidarum). The young patient has said very little in response to the questions but Maria does admit to sexual intercourse and no recent periods. Given this information, the nurse formulates the care priorities for Maria. Although her physical condition and that of the fetus warrant immediate priority, the nurse needs to support this young girl psychologically in order to proceed with any plan. Any support people who have come with her to the ED should be identied. If there is no one with her, the nurse explains the plan of care and describes what she should expect. The nurse places Maria on the electronic fetal monitor and immediately noties the physician of her condition. Because cocaine is associated with placental abruption, the nurse must identify any recent drug use. The care plan should be developmentally oriented. The nurse implements strategies to keep Maria warm, provides emotional support and a calming presence, and continues to monitor her vital signs and her vaginal ow until the physician arrives.

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DISSEMINATED INTRAVASCULAR COAGULATION


Disseminated intravascular coagulation (DIC) is an acquired disorder of blood clotting. Affected individuals can experience widespread internal and external bleeding and clotting. Clinical symptoms may include easy bruising, the appearance of multiple petechiae, and bleeding from intravenous sites. DIC is most often triggered by the release of large amounts of tissue thromboplastin, which occurs in abruptio placentae, and in retained dead fetus (the fetus has died and is retained in the uterus for 6 or more weeks) and amniotic uid syndromes (Cunningham et al., 2005). Optimizing Outcomes Prompt identication of
clinical signs that may indicate DIC

Nursing care includes continuous maternalfetal assessment, administering the prescribed uids, blood, and blood products; and assessing for signs of complications from the replacement products. The woman is positioned in a side-lying tilt to maximize placental perfusion, and oxygen may be administered via rebreathing mask at 8 to 10 L/min or according to physician or institutional protocol. Because renal failure may result from DIC, urinary output is closely monitored; it should be maintained at more than 30 mL/hr. The patient and her family should be provided with ongoing information and emotional support (Labelle & Kitchens, 2005). (See Chapters 11, 16, and 33 for further discussion on DIC.)

RUPTURE OF THE UTERUS


Rupture of the uterus during labor is a rare but lifethreatening obstetric complication that occurs in 1 to 1500 to 2000 births (Fig. 14-8). It is most often associated with the tearing of a uterine scar (usually from a previous classic cesarean birth), uterine trauma (e.g., accidents, surgery), and a congenital uterine anomaly. Rupture of the uterus occurs more often in multigravidas than in primigravidas. Intrapartal uterine rupture may result from overdistention (e.g., multiple gestation), hyperstimulation (e.g., oxytocin, prostaglandin), external or internal version, malpresentation, or a difcult forceps-assisted birth (Cunningham et al., 2005).

When conducting a physical assessment of the pregnant woman at risk for DIC, the nurse must be alert to the following clinical signs: Bleeding from multiple sites: intravenous access site, venipuncture site, site of urinary catheter insertion Spontaneous bleeding from the gums and nose Widespread petechiae and bruising Gastrointestinal bleeding Tachycardia Diaphoresis

With DIC, the anticoagulation and procoagulation factors are activated simultaneously. Thromboplastin (a clotting factor) is released into the maternal circulation as a result of placental bleeding and the consequent clot formation. Circulating levels of thromboplastin activate widespread clotting throughout the microcirculation. This process consumes or uses up other clotting factors such as brinogen and platelets. The condition is complicated further by the activation of the brinolytic system to lyse (destroy) the clots. As a result, there is a simultaneous decrease in clotting factors and an increase in circulating anticoagulants, leaving the circulating blood unable to clot. Laboratory results reveal low hemoglobin, hematocrit, platelets, and brinogen and elevated brin split/degradation products. The priority in treatment of DIC is to correct the underlying cause and replace uids and essential clotting factors. When premature placental separation has triggered the coagulopathy, delivery of the fetus and placenta must be accomplished so that the production of thromboplastin, which is driving the process, is halted. This is accomplished with intravenous administration of heparin to stop the clotting cascade. Heparin is cautiously given close to the time of birth to decrease the likelihood of postpartum hemorrhage after the delivery of the placenta. The administration of blood and platelets is usually delayed until after completion of the heparin therapy so that the newly infused blood factors are not consumed by the widespread coagulation process. Depending on the clinical setting, antithrombin III factor, brinogen, or cryoprecipitate may also be used to restore blood clotting (Labelle & Kitchens, 2005).

Nursing Insight Understanding types


of uterine rupture
Uterine rupture may be classied as complete or incomplete. A complete rupture extends through the endometrium, myometrium, and peritoneum. When this occurs, uterine contractions stop. The woman complains of sudden, severe abdominal pain during a strong contraction followed by cessation of the pain. There is bleeding into the abdominal cavity and possibly into the vagina. An incomplete rupture extends into the peritoneum but not into the peritoneal cavity or broad ligament. Bleeding is usually internal and the woman may be asymptomatic (a silent rupture) or complain of localized tenderness and aching pain over the lower uterine segment.

Changes in fetal heart tracings such as late decelerations, decreased variability, and increased or decreased heart rate may or may not be present. Maternal signs and symptoms may include faintness, vomiting, abdominal tenderness, hypotonic uterine contractions, and lack of labor progress. As blood loss continues, the woman may exhibit signs of hypovolemic shock (hypotension; tachypnea; pallor; and cool, clammy skin). Fetal parts may be readily palpable through the abdomen. Rupture of the uterus constitutes an obstetric emergency; the type of medical management depends on the severity. A small rupture may be safely managed with a laparotomy and birth of the infant, repair of the tear, and volume replacement with uids and blood transfusions if needed. A complete uterine rupture requires hysterectomy and blood replacement.

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N u r s i n g C a r e P l a n The Patient with Abruptio Placentae


Nursing Diagnosis: Decient Fluid Volume related to active losses from premature separation of the placenta.
Measurable Short-term Goal: The patient and her fetus will maintain uid balance during the intrapartum

period.
Measurable Long-term Goal: The patient and newborn will have stable homeostatic conditions upon

discharge.
NOC Outcomes: NIC Interventions:

Fluid Balance (0601) Water balance in the intracellular and extracellular compartments of the body Blood Loss Severity (0413) Severity of internal or external bleeding/hemorrhage Fetal Status Antepartum (0111) Extent to which fetal signs are within normal limits from conception to the onset of labor
Nursing Interventions:

Fluid Management (4120) Bleeding Reduction: Antepartum Uterus (4021) Electronic Fetal Monitoring: Intrapartum (6772)

1. Monitor vital signs every 515 minutes with active bleeding or if the vital signs are not stable.
RATIONALE: The vital signs provide important information about the response of the cardiac system to active bleeding and possible development of shock. Provide continuous monitoring of the FHR and pattern. RATIONALE: The fetus reacts directly to an assault on the mothers system. Bleeding from the placenta places the fetus in distress, which is manifested by changes in the FHR. Observe the perineum and behind the patients back at least every hour for signs of active bleeding. Weigh pads as needed to estimate losses. RATIONALE: Observation of active bleeding may indicate the need for an emergency cesarean delivery. One gram of weight can be estimated to equal 1 mL of blood lost. Assess for abdominal pain, palpate fundal tone, and measure abdominal girth at the umbilicus at least each hour. RATIONALE: Concealed bleeding into the myometrium may result in a painful, rigid, board-like uterus that becomes enlarged over time. Review baseline and ongoing laboratory data including: complete blood count (CBC), clotting studies, serum electrolytes, and renal function tests. RATIONALE: Baseline information is used to alert the care providers to changes in the patients condition as additional lab tests are obtained. Maintain intravenous access with a large-bore catheter and administer intravenous uids as directed. RATIONALE: Intravenous access is required to maintain and replace uid volume. Large catheters facilitate the infusion of large volumes of uid quickly. Administer blood replacement products in a timely manner as directed. RATIONALE: The hematocrit level should be 30% or greater to prevent severe shock. Assess hourly intake and output with an indwelling urinary catheter. RATIONALE: A decrease in urine output below 30 mL/hr indicates that the patient may be developing shock. Monitor for development of abnormal clotting studies, bleeding from gums, oozing from injection sites, bruising, or petechiae and notify caregiver. RATIONALE: The patient is at risk for developing DIC because of excessive bleeding. Fibrinogen levels should be greater than 150 mg/dL. Facilitate delivery as necessary to prevent maternalfetal injury. RATIONALE: If the patient is actively bleeding, or there is any indication that she has concealed bleeding, she must be delivered to prevent hemorrhage, shock, and death.

2.

3.

4.

5.

6.

7. 8. 9.

10.

Adapted from Gilbert, E., & Harmon, J. (2003). High-risk pregnancy and delivery (3rd ed.). St. Louis, MO: C.V. Mosby.

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and abnormally adherent placental tissue (Bowes & Thorp, 2004). When complete inversion occurs, a large, red, globular mass (that may contain the still-attached placenta) protrudes 20 to 30 cm outside the vaginal introitus. A partial or incomplete inversion is not visible; instead, a smooth mass is palpated through the dilated cervix. Maternal symptoms include pain, hemorrhage, and shock. Management involves manual replacement of the fundus (under general anesthesia) by the physician, followed by oxytocin to facilitate uterine contractions and antibiotic therapy to prevent infection. Prevention (by not pulling strongly on the cord until the placenta has fully separated) is the safest and most effective therapy (Cunningham et al., 2005).

UMBILICAL CORD PROLAPSE


Umbilical cord prolapse occurs when a loop of the umbilical cord slips down below the presenting part of the fetus (Fig. 14-9). Prolapse of the umbilical cord may be occult (hidden; not visible) at any time during labor whether or not the membranes have rupturedthe cord lies beside the presenting part in the pelvic inlet. With a complete cord prolapse, the cord descends into the vagina, where it is felt as a pulsating mass on vaginal examination. It may or may not be seen. Frank (visible) prolapse most commonly occurs immediately after rupture of membranes as gravity washes the cord in front of the presenting part. Risk factors associated with cord prolapse include a long (greater than 100 cm) cord, malpresentation (e.g., breech), transverse lie, hydramnios, preterm or low-birth-weight infant, multiple gestation, and unengaged presenting part (Cunningham et al., 2005). If the presenting part does not t snugly into the lower uterine segment, the sudden gush of amniotic uid that accompanies rupture of the membranes may cause the cord to be displaced downward. Optimizing Outcomes Actions to reduce the risk
of umbilical cord prolapse

Figure 14-8 Rupture of the uterus in the lower uterine segment.

Nursing responsibilities include administering intravenous uids, blood products, and oxygen and helping to prepare the woman for immediate surgery. Since the patient is anxious and fearful, it is important for the nurse to attempt to provide emotional support for the woman and her support person throughout the process. The nurse must maintain a calm demeanor while organizing critical care for the patient. As much as possible, the patient and her support person should be involved in decision making and informed of all procedures. Depending on the circumstances, it may be appropriate to provide information about chaplain support services. The associated fetal mortality rate ranges from 50% to 75% and the maternal mortality rate may be high if treatment is not initiated immediately (Cunningham et al., 2005).

UTERINE INVERSION
Uterine inversion (uterus is turned inside out) is a rare but potentially life-threatening complication that most often results from excessive pulling on the umbilical cord in an attempt to hasten the third stage of delivery. Other contributing factors include fundal implantation of the placenta, vigorous fundal pressure, uterine atony,

If SROM has occurred, the woman should be kept on bed rest until the fetal presenting part is engaged. AROM should not be attempted until engagement has occurred. To rule out umbilical cord prolapse, the nurse should assess the fetal heart sounds immediately after spontaneous or articial rupture of the membranes.

Figure 14-9 Umbilical cord prolapse. A. Occult. The cord cannot be seen or felt during a vaginal examination. B. Complete. During a vaginal examination, the cord is felt as a pulsating mass. C. Frank. The cord precedes the fetal head or feet and can be seen protruding from the vagina.

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It is imperative that the nurse recognizes indicators of umbilical cord prolapse: fetal bradycardia with variable decelerations during contractions; observing or palpating the cord in the vagina; womans statement that she feels the cord after membrane rupture. Prolonged cord compression causes fetal hypoxia; occlusion of blood ow to and from the fetus for greater than 5 minutes is likely to result in central nervous system damage or fetal death. To relieve pressure on the cord, the examiner places a sterile gloved hand into the vagina and manually lifts the presenting part off of the umbilical cord. The patient is assisted into a position such as a modied Sims, extreme Trendelenburg, or kneechest position, which uses gravity to cause the presenting part to fall back from the cord (Fig. 14-10). The nurse administers oxygen at 10 L/min by face mask to improve oxygenation to the fetus; the physician may order administration of a tocolytic agent to reduce uterine activity and relieve pressure on the fetus. If the cord is protruding from the vagina, the exposure to room air will cause drying, which leads to atrophy of the umbilical vessels. No attempts should be made to place the cord back into the vagina. Instead, the nurse should cover the exposed segment of umbilical cord with warm, sterile saline compresses to prevent drying. Prompt delivery, often with forceps assistance, is facilitated if the cervix is fully dilated. Otherwise, the

nurse or other care provider continues to manually maintain upward pressure on the presenting part (using a hand in the vagina) until a cesarean birth can be accomplished. critical nursing action After Prolapse of the Umbilical Cord
After prolapse of the umbilical cord, immediate nursing interventions are essential: Call for assistance; notify the primary health care provider. Using the gloved examining hand, insert two ngers into the vagina to the cervix. Place one nger on either side of the cord or both ngers to one side and quickly exert upward pressure against the presenting part to relieve compression of the cord. Assist the woman into an extreme Trendelenburg, modied Sims, or kneechest position. If the cord is protruding from the vagina, wrap it loosely in a sterile towel saturated with a warmed, sterile normal saline solution. Administer oxygen at 10 L/min by face mask. Increase the IV uids; administer a tocolytic agent as ordered. Continuously monitor the FHR by internal fetal scalp electrode if possible. Provide information and support to the woman and her birth partner. Prepare for an immediate vaginal birth if the cervix is fully dilated or for cesarean birth if it is not.

Figure 14-10 Interventions to relieve pressure on a prolapsed umbilical cord until birth can be effected. A. A gloved hand is placed in the vagina to lift the presenting part off the cord. B. The maternal hips are elevated with two pillows; this intervention is often combined with a Trendelenburg position. C. The kneechest position uses gravity to shift the fetus out of the maternal pelvis.

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VARIATIONS RELATED TO UMBILICAL CORD INSERTION AND THE PLACENTA


Velamentous Cord Insertion/Vasa Previa

Circumvallate, Succenturiate, and Battledore Placenta

A velamentous insertion of the umbilical cord occurs when the fetal vessels separate at the distal end of the cord and insert into the placenta at a distance away from the margin (Fig. 14-11). The vessels are not protected by Whartons jelly and are subject to compression, rupture, and thrombosis, major complications that may lead to severe fetal distress and death. This form of cord insertion most frequently occurs with placenta previa and multiple pregnancies; it may also be associated with fetal anomalies. Rupture of the membranes or traction on the umbilical cord may tear the fetal vessels. This event produces rapid, usually fatal, fetal hemorrhage. Vasa previa occurs when the unprotected fetal vessels cover the cervical os and precede the fetus. It is usually seen with a velamentous insertion of the umbilical cord. Because the vessels are not covered with Whartons jelly, the examiner may be able to feel pulsations of the umbilical cord. Lacerations of the vessels, which can occur at any time, cause sudden fetal blood loss. The onset of sudden, painless bleeding at the beginning of cervical dilation or during rupture of membranes (ROM) may signal the presence of vasa previa; diagnosis may be conrmed by sonogram (Clark, 2004; Cunningham, 2005). Without ultrasound assessment, velamentous cord insertion is not easily detectable. The nurse may note a drop in FHR during a vaginal exam. A ready FHR return to the baseline after the exam may be indicative of a velamentous cord insertion. With any episode of vaginal bleeding, the alumprecipitated toxoid (APT) test may be used to determine the presence of fetal blood cells. After the rupture of blood vessels, fetal blood leaks into the vagina and can be readily sampled for examination. Despite the rarity of this condition, velamentous cord insertion should always be suspected and ruled out via a careful vaginal exam with cervical palpation for detection of exposed vessels. Immediate action by the medical team, prompted by the nurses critical assessments, can result in an emergency cesarean birth; best outcomes occur with early prenatal diagnosis and cesarean birth at 35 weeks or earlier (Oyelese et al., 2004).

Other placental variations and problems related to the umbilical cord insertion site include circumvallate placenta (placenta circumvallata), succenturiate placenta (placenta succenturiata), and battledore placenta. These conditions are associated with variations that occurred during placentation (formation and attachment of the placenta). The circumvallate placenta is one in which a ring composed of a double fold of amnion and chorion has formed near the fetal surface. This placental aberration has been reported to be associated with antepartum hemorrhage, preterm delivery, and fetal malformations. The succenturiate placenta contains one or two separate lobes, each with its own circulation. After childbirth, one of the separate lobes may be retained in the uterus and impede contractions, resulting in severe maternal hemorrhage. The remaining lobes must be manually removed from the uterus to prevent hemorrhage. Battledore insertion of the cord describes a condition in which the umbilical cord is implanted near the margin of the placenta. Battledore placenta may be associated with fetal hemorrhage, especially after marginal separation of the placenta (Cunningham et al., 2005).
Placenta Accreta, Placenta Increta, Placenta Percreta

Abnormal adherence of the placenta is rare and its causes are unknown. After birth, the usual maneuvers to remove the placenta are unsuccessful and laceration or perforation of the uterine wall may result. When this occurs, the woman is at high risk for hemorrhage and infection. The placental adherence may be partial or complete. Placenta accreta describes a slight penetration of the myometrium by the trophoblast. Placenta increta describes a deep placental penetration of the myometrium and placenta percreta describes placental perforation of the uterus. Depending on the degree of placental adherence (and the severity of the hemorrhage), the patient will require blood replacement and a vaginal hysterectomy may be indicated (Clark, 2004; Cunningham et al., 2005).

Figure 14-11 Variations related to umbilical cord insertion in the placenta. A. Velamentous insertion of the umbilical cord. B. Circumvallate placenta. C. Succenturiate placenta. D. Battledore placenta.

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AMNIOTIC FLUID EMBOLISM


Amniotic uid embolism (AFE) (obstruction of a blood vessel by amniotic uid) is a rare complication of the intra- and postpartum periods that is associated with a high incidence of maternal and fetal death. For mothers, the mortality rate is as high as 80%; approximately 50% of neonates who survive this event have neurological impairment (Schoening, 2006). The origins of the problem are not clear, but it is hypothesized that amniotic uid containing particles of fetal debris (meconium, hair, vernix, skin cells) escapes into the maternal circulation and causes the release of endogenous mediators such as histamine, prostaglandins, and thromboxane. Obstruction of the pulmonary vessels leads to respiratory distress and circulatory collapse. Hemorrhage, disseminated intravascular coagulation, and pulmonary edema are present to some extent in women who experience an amniotic uid embolism. AFE is not preventable because it cannot be predicted although maternal factors (including multiparity, abruptio placentae, tumultuous labor) and fetal problems (including macrosomia, meconium passage, death) have been associated with an increased risk for development (Cunningham, 2005). The nurse must recognize the rapidly deteriorating maternal condition and seek immediate help. Frequently, the rst symptom is acute dyspnea, followed by severe hypotension. Other symptoms include restlessness, cyanosis, tachycardia, respiratory arrest, shock, and cardiac arrest (Schoening, 2006).

given consideration over the fetus. While there are no easy answers to these dilemmas, the nurse can serve as a leader by organizing regular meetings during which issues of this nature can be discussed in a calm, open manner. The nurse is in a key position to help create an environment where health professionals can resolve or work through difcult dilemmas.

Collaboration in Perinatal Emergencies


Approximately 1% to 2% of pregnancies are complicated by an obstetrical emergency and require a multidisciplinary approach to provide an effective, rapid response. Communication is an essential component in all patient environments but it is critical in emergency obstetrical nursing. Team members need to collaborate to provide timely interventions that promote patient safety. Learning how to present information in a way that is nonthreatening but effective is key to promoting positive communication patterns (Clements, Flohr-Rincon, Bombard, & Catanzarite, 2007). Miller (2005) identies the hierarchical communication that often exists between physicians and nurses as detrimental to good perinatal outcomes. The need to employ healthy communication patterns to effect safe and healthy outcomes for the patient is tantamount. Effective communication does not mean that there are no followers of orders or directives. Instead, it is important for both the leaders and the followers to employ critical thinking skills. Use of the word we promotes collaboration and underscores the nurses role as a patient advocate in this effective communication style. Communicating concerns with members of the health care team
Simpson (2005a) emphasizes the critical need for effective communication among the health care team. Problems in care are encountered when people fail to collaborate or communicate. Teamwork is enhanced when everyone knows the expectations of their role in the obstetric emergency (Box 14-5). Standardization of protocols allows everyone to function more effectively and prevent poor outcomes.

critical nursing action When Amniotic Fluid Embolism Develops


The immediate management includes the administration of oxygen by face mask or cannula at a rate of 810 L/min; or resuscitation bag to deliver 100% oxygen. Nursing interventions center on support of resuscitation efforts: Prepare for intubation and mechanical ventilation. Initiate or assist with cardiopulmonary resuscitation (CPR). Position the pregnant woman in a 30-degree lateral tilt to displace the uterus. Administer intravenous uids and blood (e.g., packed cells; fresh frozen plasma). Insert indwelling urinary catheter; measure hourly urine output. Continuously monitor maternalfetal status. Prepare for emergency birth once the woman is stable. Provide ongoing information and emotional support to the woman and her family.

The maternal prognosis depends on the size of the embolism and speed and skill of the responding perinatal team. If the woman survives, she will most likely be transferred to a critical care unit for hemodynamic monitoring, blood replacement, and coagulopathy treatment. Although rapid delivery is paramount to save the fetus, a delay in delivery usually occurs to stabilize the mother. In the event of maternal cardiopulmonary arrest, for optimal fetal survival, a perimortem cesarean delivery should occur within 5 minutes (Curran, 2003). This type of a situation is very difcult for all health professionals involved in the care of the patient. An ethical conict may arise when the health of the mother is

Box 14-5 Collaborative Care Principles in Perinatal Nursing


To facilitate the team process when providing care in emergency situations, the perinatal nurse should: Employ effective communication techniques. Advocate for the patient through assertive statements. Conduct interdisciplinary reviews of all cases to identify risks. Promote team collaboration by rotating leadership roles in the case reviews. Assist in the evaluation process of all emergency cases. Use outcome measurements to evaluate safe and effective care.

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Perinatal Fetal Loss


The World Health Organization denition of perinatal death is death of the offspring occurring during late pregnancy (at 22 completed weeks gestation and greater), during childbirth and up to seven completed days of life (Smith, 2005, p. 17). Perinatal deaths can occur during the antepartum, intrapartum, or postpartum periods. A variety of causes may lead to the death of the fetus or the newborn and these are often related to obstetric complications such as placental abruption or neonatal prematurity related to genetic disorders or congenital malformations (Smith, 2005). Perinatal death is rare because the majority of the childbearing population consists of young healthy women who expect to give birth to healthy babies. This prevailing expectation among the general population constitutes a major reason why it is so difcult for all involved when a perinatal death occurs. Nursing practice has changed over the years in regard to caring for families who are dealing with a perinatal loss. During the 1960s through the 1980s, women who experienced a perinatal loss were often placed on a medical surgical unit to prevent them from hearing the sounds of infants crying. One problem with this approach lies in the fact that the most experienced professionals in perinatal nursing are not located in the medicalsurgical areas. The patient who has suffered a loss still requires all assessments and interventions involved in normal postpartum care. A nurse in the perinatal practice area can better focus on therapeutic interventions to assist the woman and her family in the grieving process. The nurse organizes and coordinates a team approach to bereavement. Different members may participate but there should be key individuals such as spiritual or religious representatives, social workers, and physicians, in addition to the nurse. It is important to identify which hospital routines associated with perinatal death might interfere with allowing the family to have options concerning decisions made regarding their infant. As an example, in some cases, the infants body might be moved to the funeral home before the family has had the opportunity to hold him or her. Many parents wish to hold their child prior to an autopsy, and they should be encouraged to do so. Before presenting the parents with their infant, the nurse should make certain the infant has been cleaned and is wrapped in a soft blanket. Depending on the cause of death, it may also be prudent to give the parents an idea of their infants appearance. Usually, parents preconceived perceptions concerning how their infant will look is much worse than the reality. Individuals from the hospital morgue or a funeral home who are involved with regular bereavement team meetings can be instrumental in developing a perinatal bereavement plan that is grounded in compassion and sensitivity. When healthy infants are discharged, it is common practice to take their picture. Photographs should also be taken when an infant has died. Parents should always be encouraged to view, touch, and hold the deceased infant. However, if they do not wish to see the infant while in the hospital, the picture provides a way for them to see their infant at a future time when they are ready. Photographs can be stored in a le and given to the parents upon their request. Use of an experienced photographer is preferred, since the

infant may not always be in the most favorable condition. The maternity unit should always have a supply of clothing and new blankets available for these infants. To provide the family as much privacy as possible from hospital workers who might not know that the family has experienced a loss it is best to have some sort of indicator outside of the room. One hospital unit places a single red rose across the door. Another places a special remembrance card outside the doorframe. Both provide an immediate identication to any hospital worker entering the room that the patient and her family have experienced a loss. All of these practices stem from the development of hospital protocols regarding bereavement. The team develops a list of critical actions and specic plans to respond to each point. There is exibility to allow the parents to be active participants in the decision making but it is also organized so that as nursing and hospital personnel change, there is consistency in the approach. Communication is another critical factor in providing care for the family who has experienced a fetal or neonatal loss. Parents report that comforting words, touch, and directed speech are helpful to them. Nurses need to avoid using phrases such as: Its Gods will. You can always have another. There was a problem with this baby. Theres always next time.

Parents respond better to acknowledgment of the infants death than to avoidance. A simple Im sorry and a touch of the hand can convey the nurses care and concern when the right words are hard to nd. It is also important for the nurse to sit and listen. Parents often have multiple feelings, which they need to share. The nurse, as the objective individual, can help interpret feelings and recommend resources to assist the family as they deal with their grief. It is essential that the perinatal care team remain sensitive to the cultural and spiritual beliefs and practices of the bereaved parents and families. (See Chapter 11 for further discussion.) To the mother whose newborn has died
When caring for the mother whose infant has died, the nurse conveys compassion by simply being available. Often, the mother nds comfort in talking about the birth experience, her infant, and how she will cope with her loss. The nurse can gain insights into the mothers support systems by asking the following questions: What are you most worried or fearful about? How supportive is the babys father and your family or friends? What coping techniques have been helpful for you in the past? (Gilbert, 2006)

A perinatal loss might be the rst experience a family has with death. It is a confusing, anxiety-provoking time that often creates a fear that it will happen again. Death of a child of any age is also viewed as unnatural. Parents expect

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their children to die after themnot before them. Dreams and expectations for the lost child will now never be realized. A resource guide given to the family on discharge is an important tool to help them cope with their loss. Since much of the grieving work is done after the hospitalization, family members need to know where to call for help. A support group that includes someone from the bereavement team can offer the parents a connection to the hospital. Some parents nd this helpful in acknowledging the existence of their child while others feel more comfortable with the support of a close family network. The key is that the family is supported through their loss and is able to move through the grief process toward resolution. It is important to understand that many families will never totally come to terms with the untimely death of a child, regardless of the age of the infant or fetus.

INDICATIONS
Cesarean birth is performed when the health of the mother or her fetus is jeopardized. Maternal medical risk factors most closely associated with cesarean birth include hypertensive disorders, active genital herpes, positive HIV status, and diabetes. Fetal complications most closely associated with cesarean birth include CPD, malpresentations (i.e., breech, shoulder), placental abnormalities (e.g., abruptio, previa), dysfunctional labor patterns, fetal distress, multiple gestation, and umbilical cord prolapse. In actuality, few absolute indications exist for cesarean birth and most are primarily performed for the benet of the fetus (Martin et al., 2005). Elective cesarean births have been on the rise since 1985. In contemporary society, women are requesting cesarean births for reasons other than medical, obstetric, or fetal complications. One reason is related to a fear of vaginal birth, or tocophobia. Others are concerned about the potential for future problems with pelvic support or sexual dysfunction related to perineal or rectal injury. Some women view cesarean birth to be an empowering experience and wish to choose the birth method and date rather than have it selected for them (Tillett, 2005; Williams, 2005). At issue is the question of whether or not an elective cesarean birth is more benecial or harmful to a woman and her baby than a vaginal birth (Hannah, 2004). The Association of Womens Health, Obstetric and Gynecologic and Neonatal Nurses (AWHONN) supports the need to learn more about the nature of elective cesarean birth. AWHONN calls for continued research into strategies to decrease traumas associated with vaginal birth and subsequently decrease the need for elective cesarean birth due to maternal fear (Simpson & Thorman, 2005; Wax, Cartin, Pinette, & Blackstone, 2004; Williams, 2005). Cesarean birth is a major surgical procedure that carries risks and complications. It is associated with a host of potential postoperative problems such as hemorrhage, thromboembolism, and infection during the postpartum period. The surgery can result in adhesions, dehiscence of the wound, and problems with the placenta in subsequent pregnancies (Porter & Scott, 2003). Zelop and Heffner (2004) report that women face a higher incidence of death during a surgical procedure with the use of general anesthesia. Women are also at greater risk for intraoperative surgical complications such as lacerations of the uterus and bladder. In addition, there is a greater likelihood for hysterectomy associated with cesarean birth than with vaginal birth.

CULTURAL ASPECTS OF LOSS


In a cultural context, death has many views. There are different ways of grieving. Tears and emotional outbursts are common to some cultures while others are quiet and introspective. The nurse needs to have an awareness and understanding of how different cultural groups interpret the meaning of death and the factors that govern their response to death. The Hispanic culture that includes Mexicans, Puerto Ricans, and Cubans views children as their future. The loss of a child denies that future. They welcome touch from others and expect health care professionals to respect their need for extended family during this time frame. All cultures should be treated with sensitivity, respect and caring (Gilbert, 2006).
Now Can You Discuss Issues Concerning Perinatal Death?
1. Identify signicant members of the bereavement team? 2. Discuss interventions for families experiencing a perinatal loss? 3. Voice some comments that would be helpful for a grieving family?

Cesarean Birth
DEFINITION AND INCIDENCE
Cesarean birth is the birth of a fetus through an abdominal incision into the uterus; it is performed to preserve the life of the mother and her fetus. In 1965, the rate of cesarean births in the United States was less than 5% (Hamilton et al., 2005). Preliminary data for 2005 indicate that 30.2% of all live births in this country were cesarean births, marking the highest U.S. total cesarean rate ever reported. Since 1996, the number of cesarean births has increased by 46%, driven by both an increase in the percentage of all women having a rst cesarean and a decline in the percentage of women who gave birth vaginally after a previous cesarean birth (CDC, 2007). Modern surgical advances and the use of antibiotics have resulted in a decrease in maternal and fetal morbidity and mortality. However, despite these advances, cesarean birth is a major surgical procedure that poses threats to the health of the mother and her infant.

ETHICAL CONSIDERATIONS OF ELECTIVE CESAREAN BIRTH


If it is more dangerous to have an elective cesarean birth than a vaginal birth, is it ethical to allow the woman to select this as her birth method of choice? Wax (2004) discusses the contrast between benecence (the principle of doing good) and the physicians responsibility to do no harm and the patients right to autonomy. The American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics maintains that if a patient requests a cesarean birth, and the physician believes that the overall health of the mother and fetus will benet, then the elective cesarean delivery has merit (ACOG, 2003b). If the physician does not think a cesarean method of birth is in

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the best interest of the patient, the patient should be informed and given the right to select another physician. However, the issue is far more complex than this simple example. Williams and Shah (2003) plead for a return to common sense. Birth is a normal and natural event. These authors raise the following questions: Have we become a nation so obsessed with expediency and control that we are willing to relinquish our humanity to technology? Are we truly willing to sacrice our health and future childbearing for the lure of birth by appointment? Are our demands for perfection or compensation unnecessary interventions (p. 284)? All women are entitled to unbiased information and a safe, supportive environment. Continued studies that examine the myriad issues concerning aspects of benet versus harm including the economic ramications of elective cesarean birth are in order.

SURGICAL PROCEDURES
There are two main types of cesarean operations: the classic (vertical) incision and the lower-segment transverse (LST) incision (Fig. 14-12). The surgeon chooses the incision type based on the patients condition and the fetal status. Rarely used today, the classic cesarean incision is reserved for some cases of shoulder presentation, placenta previa, and when birth must take place immediately. Since this type of uterine incision is associated with complications including considerable blood loss, infection, and uterine rupture with subsequent pregnancies, women who undergo classic cesarean births may not attempt future vaginal births. The lower segment cesarean (preferred by women for cosmetic reasons) may involve either a vertical or a transverse uterine incision. The transverse incision, more commonly performed, is associated with less blood loss, fewer postoperative infections, and a decreased likelihood of uterine rupture during subsequent pregnancies (Bowes & Thorp, 2004; Cunningham et al., 2005). The skin incision made into the abdomen is either transverse (sometimes called a Pfannenstiel or bikini incision) or vertical

(sometimes called a midline incision). The skin incision may or may not be the same type of incision that is made into the abdomen. After the skin incision, the surgeon carefully moves through the tissue layers to the uterus. An incision is made into the uterus and the fetal head is gently elevated through the opening. A patent airway is established and the rest of the fetus is delivered. The cord is clamped and the newborn is placed, depending on the circumstances, either in the arms of the parent or in the neonatal warmer. After removal of the placenta, the incision is sutured at each layer and a sterile bandage is placed over it (Cunningham et al., 2005; Porter & Scott, 2003). The nurse documents all components of patient care including the time of birth and offers ongoing encouragement and support to the mother. Once the birth has taken place, the nurse facilitates attachment with the new family. When complications are present, the nurse provides information including a description of the newborn to the family. If the newborn requires resuscitation or a transfer to the neonatal intensive care unit, the family is allowed to view the neonate in the isolette before transport. When the newborns condition is satisfactory, the newborn is presented to the parent or support person to hold. Although the mother is restrained by surgical equipment, the parent or support person can hold the baby close to the mothers face so that she can see her child. This initial bonding experience can usually take place while the surgeon completes the suturing process. The family is then moved to the recovery room for post-surgical care.

NURSING CARE
In most instances, the patient scheduled for a planned cesarean birth is admitted on the day of surgery. When the need for an emergency or unplanned cesarean arises, the patient undergoes the same procedures but in a more timely manner. Blood work, including type and cross match and a complete blood count, is obtained before admission and the results are entered in the chart. The woman has been instructed to remain NPO since midnight before admission. The nurse orients the patient to the unit, reviews the prenatal history, and responds to any questions or concerns. An informed consent is signed. A fetal monitor is placed on the patients abdomen for a 20- to 30-minute baseline assessment. Vital signs are taken and charted. In preparation for the surgery, the abdomen is cleaned and shaved, an intravenous line is placed, and an indwelling urinary catheter is inserted to keep the bladder empty during the operation. Medications are administered according to the physicians orders. If an epidural anesthetic is to be used, the nurse properly positions the patient and supports her during its administration. If a general anesthetic is to be used, an oral antacid may be prescribed to neutralize gastric secretions in the event of aspiration. The woman is then transported to the operative suite (Simpson & Creehan, 2001). Optimizing Outcomes Enhancing maternal
anesthesia knowledge and choice

Vertical

Transverse

Low transverse

Low vertical

Classic

Figure 14-12 Abdominal wall and uterine incisions for cesarean births. A.Skin (abdominal wall) incisions. Vertical and transverse (Pfannenstiel). B.Uterine wall incisions. Low transverse, low vertical, classic.

Spinal, epidural, and general anesthesia are used for cesarean births. Although epidural anesthesia is a popular choice because the woman may remain awake during the birth

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experience, the type of anesthesia used depends on factors such as the maternal medical history and current status, and how quickly the birth needs to take place. In addition, the woman is a factorshe may harbor fears about having an anesthetic injected into her back. Patients should be given information including the risks and benets associated with the different types of anesthesia to empower them to make an informed decision whenever there is a choice.

SURGICAL CARE
The nurses role varies during the surgical procedure. Depending on the hospital setting and protocols, one nurse assists the physician during the procedure while another nurse circulates. A team consisting of a neonatal nurse and a neonatologist or nurse skilled in neonatal resuscitation is in attendance to provide care for the infant. The patient is placed on the surgical table with a hip wedge to slightly elevate the hips. The fetal heart rate is continuously monitored until the patients abdomen is ready for surgical preparation according to hospital protocol. The support person, dressed in appropriate surgical attire, may be present at any point in the process but is usually asked to wait until the surgical drapes are in place before being seated by the patients head. The anesthesiologist monitors the maternal vital signs and the intravenous solutions. When the woman remains awake during the procedure, the nurse and other members of the care team provide information about the events taking place and sensations that the woman may be experiencing. Continued support and explanations help to decrease anxiety, enhance feelings of comfort, and help the woman to maintain a sense of control in the unfamiliar and perhaps frightening, environment.

reported that research conducted during that time provided evidence that a VBAC was safe and a more costeffective birth alternative. This movement also coincided with the growing concern in the United States over the dramatic increase in cesarean birth rates, especially among women requiring a repeat cesarean birth. In 1988, the American College of Obstetricians and Gynecologists (ACOG), having concluded that women with a low transverse incision could safely be allowed a trial of labor and possible vaginal birth, released a statement in support of VBAC. ACOG endorsed the practice of oxytocin administration, epidural anesthesia, and early ambulation for women with previous cesarean births who met certain criteria. A standby team prepared to perform a cesarean birth in the event of an emergency was to be available at all times (Dauphinee, 2004). Numerous studies supported the success of VBAC. During the 1990s, approximately 60% to 80% of women who underwent a trial of labor following a previous cesarean were able to give birth vaginally with minimal complications (Porter & Scott, 2003). Safety concerns arose although data showed that uterine rupture, the most serious of complications, was a rare event. In response to these concerns, physicians began to more closely restrict the types of patients allowed to attempt a trial of labor. Criteria for the selection of candidates for a trial of labor have been developed (Box 14-6). A critical point conrmed by the studies was that VBACs needed to be performed in large hospitals or tertiary level centers since these institutions offer continued 24-hour anesthesia coverage necessary to prevent perinatal mortality and morbidity if uterine rupture occurs (Porter & Scott, 2003).

NURSING IMPLICATIONS
To provide safe, effective care, it is essential that nurses who care for patients in the labor and birth suite have received extensive training in fetal monitoring interpretation. At the rst sign of any abnormality in the fetal heart rate tracing, the nurse must alert the physician or certied nurse midwife. Meticulous documentation is critical, as it provides essential information to other members of the health care team. For the elective cesarean birth, informed consent is obtained in the physicians ofce before admission and the nurse conrms this with the patient. Once patients actually experience labor, it is possible for them

POSTOPERATIVE CARE
After the completion of the surgery, the woman is transferred to a recovery room or to her labor room. According to agency protocol, the nurse assesses various aspects of the recovery progress, including effects from the anesthesia, the status of the postoperative/postbirth uterus, and the degree of pain. If a general anesthetic was used, special attention is given to maintenance of a patent airway. The patient is positioned to prevent aspiration and vital signs are assessed every 15 minutes for the rst 2 hours, or until stable. The nurse frequently inspects the incisional dressing and assesses the fundus, the amount of lochia, the intravenous infusion, and the urinary output. The woman is assisted to turn, cough, deep breathe, and perform leg exercises. Pain medications are administered as needed. If the neonate is with the mother and her labor support, time is provided to facilitate family bonding and attachment. If the woman wishes to breastfeed, she is encouraged to do so. Patients generally remain in the recovery area for 1 to 2 hours before transfer to the postpartum unit for continued care. (See Chapter 15.)

Box 14-6 Selection Criteria for Vaginal Birth After Cesarean Birth (VBAC)
One previous low-transverse cesarean birth (If two prior cesarean births, only those who have also had a vaginal birth as well should be considered candidates for a spontaneous labor) Clinically adequate pelvis in relation to fetal size No other uterine scars, anomalies, or previous rupture Physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean birth Availability of anesthesia and personnel for emergency cesarean birth
Source: American College of Obstetricians and Gynecologists (ACOG). (2004a). Vaginal birth after previous cesarean delivery (Practice Bulletin No. 54). Washington, DC: Author.

VAGINAL BIRTH AFTER CESAREAN


There is an old adage, once a cesarean, always a cesarean. During the 1970s and 1980s, women challenged this rule and fought for the opportunity to attempt a vaginal birth after a cesarean birth (VBAC). Dauphinee (2004)

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to change their minds and, depending upon the circumstances, they may choose not to have a vaginal birth. As in other situations, the nurse responds to questions and concerns and ascertains the patients understanding of the associated benets and risks (Dauphinee, 2004). During the entire labor process the nurse is alert for any changes in the maternalfetal condition. The FHR pattern and uterine activity are usually monitored electronically during the active phase of labor. Non-reassuring FHR patterns such as prolonged decelerations, late decelerations, and variable decelerations, may precede uterine rupture or herald its occurrence. The nurse continuously evaluates the womans level of pain. Uterine rupture may be accompanied by abdominal, shoulder, or back pain even when epidural anesthesia has been administered. However, the nurse should frequently palpate the uterus for signs of rigidity since the patient may report no pain. Since there is always the possibility of an emergency at any time, the nurse must be prepared to react in a calm manner. As the labor progresses, the patient and her support(s) should receive reassurance and information regarding any change in the plan of care (Dauphinee, 2004).
Now Can You Discuss VBAC?
1. Name ve criteria for a patient to be allowed to attempt a vaginal birth after a previous cesarean birth? 2. Discuss possible patient concerns regarding VBAC and how the nurse should appropriately respond to them? 3. List three specic nursing implications associated with the care of the woman who is experiencing a VBAC?

of factors that contribute to the rise in cesarean births. The results of such studies may lead to a decrease in the overall cesarean birth rate, which has risen steadily throughout the last decade. Nurse educators in the community can provide supportive interventions for all of these issues. Counseling during the prenatal period to allay anxieties and fears is critical. Families also need realistic plans for the childbirth along with thorough explanations of procedures and what they should expect (Tillett, 2005). Prepared childbirth classes have increased in numbers and variety in the United States. Although many health educators serve an important role, the nurse with a clinical practice in obstetrics and womens health is in an ideal position to offer constructive guidance to families. Families need to learn to advocate for themselves through increased knowledge and understanding of the issues surrounding operative deliveries. If womens fears concerning childbirth are lessened, they become more open to teaching and can begin to function as collaborators in their own care. For example, perinatal education and selective tension-reducing labor techniques may reduce the womans fear of labor and birth. Perhaps women who are able to overcome their fear of labor will choose to attempt vaginal birth instead of an elective cesarean birth. Nurses who serve as childbirth educators have a unique opportunity to empower women and their families through education and this new knowledge and self condence may translate into a reduction in the rate of cesarean births.

Postterm Pregnancy/Prolonged Pregnancy


A postterm pregnancy is dened as one that extends beyond 294 days or 42 weeks past the rst day of the last normal menstrual period. Stated another way, a postterm pregnancy has gone at least 1 day past 42 completed weeks (gestational age 421). A similar term, postdate, identies a pregnancy that has gone past the estimated date of birth. It is estimated that postterm pregnancies occur in approximately 3% to 12% of all pregnancies. Prolonged pregnancies are at risk for a number of problems including fetal macrosomia associated with shoulder dystocia and fetal injury, oligohydramnios, meconium aspiration, intrapartum fetal distress, and stillbirth. Neonatal problems may include asphyxia, meconium aspiration syndrome, hypoglycemia, polycythemia, respiratory distress, and dysmaturity syndrome (Gilbert, 2006). Maternal risks such as trauma, hemorrhage, infection, and labor abnormalities are also associated with postterm pregnancy. Labor interventions including induction with prostaglandins or oxytocin, forceps- or vacuum-assisted birth and cesarean birth are more likely to be needed. In addition, the woman may experience fatigue and psychological responses such as depression, frustration, loss of control, and feelings of inadequacy as the pregnancy extends beyond the estimated date of birth (ACOG, 2004b; Moore & Martin, 2003). The exact cause of postterm pregnancy is unknown. However, a possible cause may be related to a deciency of placental estrogen and the continued secretion of progesterone. Low levels of estrogen may result in a decrease

RESEARCH FINDINGS AND IMPLICATIONS


The rising rate of cesarean births and the decrease in the number of vaginal births after cesarean births (VBAC) are related. The higher the number of rst-time mothers who experience a cesarean delivery, the higher the number of women who may not have a choice for a vaginal delivery the next time if their physician is reluctant to attempt a VBAC. Medical studies currently question the rising cesarean birth rate. Kabir and colleagues (2004) evaluated a large database of U.S. patients and concluded that a high proportion of unnecessary cesarean births occur. For study purposes, an unnecessary cesarean birth was dened as one that occurred when there were no identied medical risks or adverse circumstances. The adverse consequences of higher cesarean birth rates contribute to an increase in maternal morbidity and mortality. In addition, there are signicant economic costs related to the prolonged hospital stays and the increased need for expensive surgeryrelated technologies. Although the greatest concern centers on the health and safety of the mother and her fetus, burgeoning health care costs cannot be discounted as a problem (Kabir et al., 2004). Nurse researchers should continue to examine evidence to provide a better understanding of the factors that impact the cesarean birth rate. A few of the modiable variables include maternal obesity, fear of labor and delivery, physiological pushing techniques, fear of injury, and convenience in planning a birth. Nurses need to engage in clinical research designed to offer evidence identifying the myriad

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in prostaglandin precursors and the reduced formation of myometrial oxytocin receptors (Gilbert, 2006). A woman with a history of one postterm pregnancy is more likely to experience another with subsequent pregnancies (Divon, 2002). Because the placenta ages rapidly past the fortieth week of gestation, it becomes inefcient and cannot adequately support the fetus. A decrease in oxygen and nutrients results in fetal hypoxic episodes. Hypoxic events that occur on a regular basis stress the fetus. When labor commences, the postterm compromised fetus is at a greater risk for severe distress than the nonstressed term infant (Gilbert, 2006). Antenatal testing combined with careful expectant management is used to monitor fetal status beyond the fortieth week of gestation. Antenatal testing is not viewed as a predictor of an untoward event but as a way to identify the fetus that demonstrates signs of compromise. The antenatal assessments most often obtained include nonstress tests (NST), biophysical proles (BPP), amniotic uid volume (AFV) measurements and maternal daily fetal movement counts. Other tests include the contraction stress test (CST), which relies on oxytocin-stimulated contractions to identify FHR decelerations associated with fetal hypoxia and Doppler ow measurements. The tests are usually performed on a weekly or twice-weekly basis (Cunningham et al., 2005; Divon, 2002). (See Chapter 11 for further discussion.)

increased anxiety when their due date has passed and they are still pregnant. The nurse is in a position to provide a consistent presence and respond to any questions or concerns. If induction is decided as the treatment option, the nurse explains the procedure to the patient and again responds to questions and concerns. Intrapartal nursing care centers on close maternalfetal surveillance and continued emotional support. During labor, the fetus should be monitored electronically to obtain an accurate assessment of the FHR and pattern. Umbilical cord compression, which is more likely to occur in the presence of decreased amniotic uid, results in fetal hypoxia. Variable or prolonged deceleration patterns and the passage of meconium are reective of fetal hypoxia. If oligohydramnios is present, amnioinfusion may be performed to restore the amniotic uid volume to provide a uid cushion for the umbilical cord (Cunningham et al., 2005).

summar y poi nt s

MEDICAL MANAGEMENT
If a woman does not experience spontaneous labor by the 42nd week (sometimes earlier), induction is considered the primary medical management choice. Expectant management, including daily kick counts, weekly monitoring of the amniotic uid index, and non-stress testing provide information regarding fetal well-being but are not always conclusive. If the gestational age is documented by ultrasound to be beyond 42 weeks and the cervix is favorable, most physicians proceed with labor induction. A cervix that is favorable (i.e., one that has begun to efface and dilate) is more conducive to the induction. If the cervix is not favorable, a cervical ripening agent (e.g., prostaglandin insert or gel) may be administered, followed by oxytocin induction (ACOG, 2004b; Resnik & Resnik, 2004). Some women with an unfavorable cervix may choose to continue with careful daily monitoring instead of the induction. As long as the physician considers the surveillance to be a safe option, the patient may be allowed to continue with the process of expectant management. However, if spontaneous labor does not begin by the 42nd or 43rd week, most physicians proceed with induction (Beckman et al., 2002).

The nurse serves in many capacities when managing the care of women experiencing a complicated labor and birth; a strong theoretical background provides a foundation for the necessary critical decision-making Dystocia, a long, difcult or abnormal labor, may arise from any of the three major components of the labor process: the powers, passenger or passageway During a trial of labor, nursing responsibilities center on assessment of maternal vital signs and fetal heart rate and pattern Oxytocin used during labor induction and augmentation should always be administered as a piggyback solution, and a uterine and FHR monitor should be used continuously during the infusion Forceps and vacuum extraction are methods to assist birth; the mother and the infant require special observation during and after these procedures The management of hypertensive disorders during intrapartum is focused on preventing further deterioration of affected organs and fostering a positive maternalfetal outcome Cesarean birth, which may be a scheduled or emergency procedure, is associated with increased risk for the mother and her infant and should be undertaken only when medically necessary Perinatal loss necessitates a collaborative response from all professionals involved in the care of the patient

r evi ew quest i ons


Multiple Choice

NURSING IMPLICATIONS
The nurse conducts the non-stress and nipple stimulation contraction stress tests in the antepartum clinical setting, interprets information for the patient and provides reassurance. The nurse must be cautious in providing only the factual information. Since there is a possibility of false readings, the nurse must avoid offering unfound reassurances and immediately notify the physician if test results are not normal. Understandably, patients often experience 1. When reviewing hypotonic labor, the perinatal nurse explains to a student nurse that the leading cause of this dysfunctional labor pattern is: A. Fetal macrosomia B. Maternal android pelvis C. Inadequate uterine pacemakers D. Fetal occiput posterior position

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2. The perinatal nurse is aware that the minimal amount of uid that would be infused for an amnioinfusion is: A. 500 mL B. 300 mL C. 250 mL D. 800 mL 3. The perinatal nurse understands that one of the risks of oxytocin infusion includes fetal heart rate changes related to: A. Decreased placental perfusion B. Oligohydramnios C. Maternal hypotonic contractions D. Maternal hypotension
True or False

4. The perinatal nurse understands the denition of hypotonic labor to be one that has fewer than ve contractions in a 10-minute period. 5. The perinatal nurse is aware that clinical signs that require discontinuation of an amnioinfusion include maternal shortness of breath or tachycardia. 6. The perinatal nurse recognizes that the presence of hydramnios, which occurs when there is an excessive amount of amniotic uid, may increase the risk of prolapsed umbilical cord following rupture of membranes.
Fill-in-the-Blank

7. The perinatal nurse knows that fetal macrosomia is signicantly related to maternal __________ measurement and _____________ _______________. 8. After a precipitous birth, the perinatal nurse carefully assesses the mother and her neonate for signs or symptoms of _________. 9. In providing information to a woman in labor who is to have an amniotomy, the perinatal nurse identies ______________ to be one of the procedures risks, which means that there will be a commitment to have this birth occur in a timely manner.
Case Study

10. The perinatal nurse is caring for Christy, a 22-year-old G3 TPAL 1011, who is 9 cm. dilated and contracting every 2 to 3 minutes. Her labor has been rapid and she has been admitted in the last 30 minutes. Christys membranes rupture spontaneously and the perinatal nurse is not able to auscultate the fetal heart. The most immediate nursing action is to: A. Check the perineum for the possibility of a prolapsed umbilical cord. B. Reposition the Doppler to attempt to auscultate the fetal heart rate. C. Reposition Christy to a left lateral position. D. Reassure Christy that her labor is progressing well. See Answers to End of Chapter Review Questions on the Electronic Study Guide or DavisPlus.
REFERENCES
American College of Obstetricians and Gynecologists (ACOG). (1999). Induction of labor (Practice Bulletin No. 10, pp 603612). Washington DC: Author.

American College of Obstetricians and Gynecologists (ACOG). (2001). Gestational diabetes (Practice Bulletin No. 30, pp 695708). Washington, DC: Author. American College of Obstetricians and Gynecologists (ACOG). (2002a). Diagnosis and management of preeclampsia and eclampsia (Practice Bulletin No. 33). Washington, DC: Author. American College of Obstetricians and Gynecologists (ACOG). (2002b). Shoulder dystocia (Practice Bulletin No. 40). Washington, DC: Author. American College of Obstetricians and Gynecologists (ACOG). (2003a). Management of preterm labor (Practice Bulletin No. 43). Washington, DC: Author. American College of Obstetricians and Gynecologists (ACOG). (2003b). New ACOG opinion addresses elective cesarean controversy, ACOG news release, October 31, 2003. Washington, DC: Author. American College of Obstetricians and Gynecologists (ACOG). (2004a). Vaginal birth after previous cesarean delivery (Practice Bulletin No. 54). Washington, DC: Author. American College of Obstetricians and Gynecologists (ACOG). (2004b). Management of postterm pregnancy (Practice Bulletin No. 55). Washington, DC: Author. American College of Obstetricians and Gynecologists (ACOG). (2005). Intrapartum fetal heart rate monitoring (Practice Bulletin No. 70). Washington, DC: Author. Ananth, C., Oyelese, Y., Yeo, L., Pradhan, A., & Vintzileos, A. (2005). Placental abruption in the United States, 1979 through 2001: Temporal trends and potential determinants. American Journal of Obstetrics and Gynecology, 192(1), 191198. Baxley, E., & Gobbo, R. (2004). Shoulder dystocia. American Family Physician, 69(7), 5768. Beckman, C., Ling, F., Laube, D., Smith, R., Barzansky, B., & Herbert, W. (2002). Obstetrics and Gynecology (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Belfort, M. (2003). Operative vaginal delivery. In J.R. Scott, R.S. Gibbs, B.Y. Karlan, & A.F. Haney (Eds.), Danforths obstetrics and gynecology (9th ed., pp. 419447). Philadelphia: Lippincott Williams & Wilkins. Bernasko, J. (2004). Contemporary management of type I diabetes mellitus in pregnancy. Obstetrical and Gynecological Survey, 59(8), 628636. Bowes, W., & Thorp, J. (2004). Clinical aspects of normal and abnormal labor. In R. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Principles and practice (5th ed.). Philadelphia: W.B. Saunders. Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interventions classication (NIC) (5th ed.). St. Louis, MO: C.V. Mosby. Camune, B., & Brucker, M.C. (2007). An overview of shoulder dystocia. Nursing for Womens Health, 11(5), 490498. Canavan, T., Simhan, H., & Cartis, S. (2004). An evidenced-based approach to the evaluation and treatment of premature rupture of membranes. Part II. Obsterical & Gynecological Survey, 59(9), 678689. Centers for Disease Control and Prevention (CDC). (2007). Quick Stats: Percentage of all live births by cesarean deliveryNational vital statistics system, United States, 2005. MMWR Morbidity and Mortality Weekly Report, 56(15), 12. Chan, P., & Winkle, C. (2006). Gynecology and obstetrics: Current clinical strategies. Laguna Hills, CA: CCS Publishing. Church, S., & Hodgson, T. (2003). Disordered uterine action In J.R. Scott, R.S. Gibbs, B.Y. Karlan, & A.F. Haney (Eds.), Danforths obstetrics and gynecology (9th ed., pp. 876883). Philadelphia: Lippincott Williams & Wilkins. Clark, S. (2004). Placenta previa and abruptio placentae. In R. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Principles and practice (5th ed.). Philadelphia: W.B. Saunders. Clements, C.J., Flohr-Rincon, S., Bombard, A.T., & Catanzarite, V. (2007). OB team stat: Rapid response to obstetrical emergencies. Nursing for Womens Health, 11(2), 194198. Culver, J., Strauss, R., Brody, S., Dorman, K., Timlin, S., & McMahon, M. (2004). A randomized trial of intracervical Foley catheter with concurrent oxytocin compared to vaginal misoprostol for labor induction in nulliparous women [Supplement]. American Journal of Obstetrics & Gynecology, 185(6), S203. Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., & Wenstrom, K. (2005). Williams obstetrics (22nd ed.). New York: McGraw-Hill. Curran, C. (2003). Intrapartum emergencies. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32(6), 802813. Dauphinee, J. (2004). VBAC: Safety for the patient and the nurse. Journal of Obstetric Gynecologic and Neonatal Nursing, 33(1), 105115.

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chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth
Williams, D. (2005). The top 10 reasons elective cesarean section should be on the decline. AWHONN Lifelines, 9(1), 2324. Williams, D., & Shah, M. (2003). Soaring cesarean section rates: A cause for alarm. Journal of Obstetric Gynecological and Neonatal Nursing, 32, 283284. Wing, D.A. (2002). A benet-risk assessment of Misoprostol for cervical ripening and labour induction. Drug Safety, 25(9), 665-676. Yang, Q., Wen, S., Chen, Y., Krewski, D., Fung, K., & Walker, M. (2005). Occurrence and clinical predictors of operative delivery of

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the vertex second twin after normal vaginal delivery of the rst twin. American Journal of Obstetrics and Gynecology, 192(1), 178184. Young, T., & Woodmansee, B. (2002). Factors that are associated with cesarean delivery in a large private practice: The importance of prepregnancy body mass index and weight gain. American Journal of Obstetrics & Gynecology, 187(2), 312320. Zelop, C., & Heffner, L. (2004). The downside of cesarean delivery: Shortand long-term complications. Clinical Obstetrics and Gynecology, 47(2), 386393.

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CONCEPT MAP
Caring for the Woman Experiencing Complications During Labor and Birth

Complications of Labor

Placental Complications

Maternal Complications

Fetal Complications

Other Complications

Dysfunctional labor Hypertonic labor Hypotonic labor Precipitate labor

Nursing ID labor pattern Frequent monitoring: Vital signs Reexes Cervical dilation, effacement Contractions Teach breathing, relaxation Provide information, reassurance

Placenta Previa Collaborate with medical treatment plan Placental Abruption Continuous fetal monitor Frequent vital signs Assess perineum, urine output, labs

May necessitate

Preeclampsia Manage HTN Fetal monitoring Vitals/neurological Urine output/edema Watch labs for HELLP MgSO4 monitoring Diabetes FSBG q 2 hours Possible insulin drip Prepare for C-birth Preterm labor Maternal and fetal monitoring Correct application of monitoring equipment and interpretation of tracings

Fetal Malpresentation Consent for version Prep for C-birth Cephalopelvic Disproportion Position changes Relaxation, water therapy Pain management Multiple Gestation Careful monitoring Assess individual fetal heart rates Fetal compromise Immediate MD notication Assess acid/base Position change Oligohydramnios Hydramnios Meconium Staining Nuchal cord

Uterine rupture Uterine inversion Prolapse of the umbilical cord Vasa previa/ velamentous insertion Amniotic uid embolism

Nursing Obtain consent Monitor labor: vitals, fetal heart tones, contractions, cervical changes, fetal station/lie Monitor oxytocin rate, side effects, urine output Pain management Positioning

Obstetric Interventions Amnioinfusion Amniotomy Pharmacological induction Complementary measures Instrumentation assistance

Perinatal Fetal Loss Often due to obstetric complications Team approach to bereavement: organized, culturally sensitive, exible plan Allow parental decisions Communication Support groups

Cesarean Birth When health of mother/fetus in jeopardy Major surgical procedure Ethical concerns Involves care of the postoperative patient Concerns re:VBAC

Across Care Settings: Collaborative care for multiple gestation birth

Critical Nursing Actions: Assisting with precipitous birth Caring for the patient undergoing amnioinfusion Responding to umbilical cord prolapse

Ethnocultural Considerations: Level of quality of care differs between white and non-white populations

What To Say: For preterm labor: active listening, explore concerns Calm, factual explanation during fetal distress Effective team communication during obstetric emergencies Conveying compassion in fetal loss

Now Can You: Identify factors that impede labor progression Explain the difference between labor induction and augmentation Explain correct procedure for application of the fetal monitor Discuss care and medical management of twin births Discuss issues and appropriate communication concerning perinatal death

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