High Risk Labor
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What is dystocia?
- Abnormal labor that does not progress
- Related to the power, passenger, passageway,and psyche of the mother
- Length of labor may be unusually short or long
- May need operative birth
- More likely to result in injury to the fetus or the mother
What are the risk factors for dystocia?
- Over distention of the uterus r/t polyhydramnios or multiple gestation
- Abnormal presentation
- Over-stimulation of the uterus (may be due to too much pitocin)
- Maternal fatigue, dehydration, fear
- Lack of analgesic effect for the woman who is not coping well
What are the risk factors for dysfunctional labor patterns?
- Congential uterine abnormalities such as bicornicate uterus
- Malpresentation of the fetus
- Tachsystole of the uterus with oxytocin
- Maternal fatigue or dehydration
- Admin of analgesia or anesthesia early in labor
- Maternal Fear
Describe hypertonic and hypotonic Uterine Dysfunction
- Hyptertonic Uterine Dysfunction:
- - called prodromal labor early on
- -occurs primarily in the active phase
- -frequent contractions
- -inadequate uterine relaxation
- -little or no cervical changes
- Hypotonic Uterine Dysfunction:
- -decreased frequency, duration, and strength of contractions
- -little or no cervical change
What maternal and fetal risks do dysfunctional labor patterns pose?
- -Increased discomfort r/ uterine muscle cell ---Anoxia
- -Stress on coping abilities
- -nonreassuring fetal status r/ decreased uteroplacental exchange
- -caput succadaneum
- -excessive molding
What is the treatment for dysfunctional labor patterns?
- If vaginal birth is deemed appopriate....
- -sedation and pain relief for mother to promote rest (such as morphine, demerol, or ambien)
- -Hydration to improve uterine perfusion
- -Oxytocin augmentation
- -Amniotomy (pressure on the cervix promotes dilation and labor)
- Otherwise, prepare for c-birth
What is precipitous labor, what risks are involved, and how is it treated?
- Entire labor an birth within 3 hrs
- Maternal Risks:
- -loss of coping abilities
- -anxiety & fear
- -lacerations of cervix, vagina, or perineum
- -Postpartum hemorrhage
- Fetal Risks:
- -fetal hypoxia r/t decreased placental circulation due to intense contractions
- -meconium stained fluid with the risk of aspiration
- -brachial plexus injury r/t rapid descent
- -low apgar
- -intracranial trauma
- -close monitoring to detect the onset of labor
- -induction to prevent unattended birth
What are the risks for "indequate expulsive forces"? How is it managed?
- Risk factors are maternal exhaustion and epidural anesthesia
- Treated with augment of oxytocin, vacuum/forceps, c-birth
- Nursing actions to promote the 2nd stage of labor is instruct for open glottis pushing, maintain adequate pain relief, and change the maternal position to facilitate fetal descent
What are common problems preventing the descent of the fetus?
- Macrosomia (Fetus >4500g/9lb)
- Multifetal pregnancy
- Fetal anomalies that interfere with fetal descent through the birth canal (such as conjoined twins, hydrocephaly)
What are some common malpresentations of the fetus that can prevent descent?
- Persistant occiput posterior (OP) position
- Cephalic malpresentations (military, brow, face)
- Shoulder presentation
- Multi fetal
What is Persistent Occiput Posterior, what are the s/s, and how is it managed?
- Most common malpresentation where the fetus does not pass easily
- May lead to lacerations and need of forceps to turn fetus
- Change maternal position to encourage a change in fetal position
- -back pain
- -dysfunctional labor pattern
- -prolonged active phase
- -arrest of dilation or descent
How can a multifetal pregnancy lead to malpresentation of the fetus and prevent descent?
- Uterine over distention contributes to poor contraction quality
- Abnormal presentation or position of one or more fetuses interferes with labor mechanisms
- Often, one baby is cephalic and the other is breech, unless a version is done
What issues with the pelvis and soft tissue can prevent fetal descent?
- The Gynecoid shaped bony pelvis is the most favorable shape for vaginal birth
- Cephalopelvic disproportion means that the head does not fit through the pelvis
- Soft tissue obstructions include include a full bladder, pelvic tumors, and cervical scarring r/t to infection or surgery
How does the woman's psyche affect the labor?
- This is the most common factors that can prolong labor
- Lack of analgesic control of excessive pain
- Absence of support persons or coaches
- Immobility and restrictions to bed
- Increased anxiety causes smooth muscle relaxation hormones to be released, such as epinephrine, cortisol, and adrenocorticotropics
- Women with psychological disorders may face additional emotional challenges during pregnancy, labor, birth and post partum
What are the indications for labor induction and augmentation?
- Renal Disease
- HTN disorders
- Fetal demise
- Hx of precipitous labor
- Mild abruption
- no fetal distress
- nonreassuring antepartal testing
- Severe olighydramnios
What are the contraindications for labor induction and augmentation?
- Vaginal birth is contraindicated in....
- -uterine scarring
- -placental abnormalities
- -Abnormal fetal presentation
- -Umbilical cord prolapse
- -Active genital herpes
- -Pelvic abnormalities
- Relative contraindications...
- -abnormal FHT
- -unknown fetal position
- -multiple gestation
- -presenting part above the maternal pelvis
- -Severe HTN
- -maternal cardiac disease
How is maternal and fetal readiness determined when considering induction or augmentation of labor?
- The bishop score measures maternal readiness by measuring the dilation, effacement, fetal station, cervical consistency, cervical position
- A Bishop score of 6 or more is favorable for induction, while a score of less than 6 needs cervical ripening
- Fetal readiness is 39 wks gestation, determined by US, a fhr present for 30 wks, or 36 wks since pos pregnancy test
What are some different methods for inducing labor?
- Cervical ripening
- Stripping of membranes
- IV Oxytocin
- Complimentary/alt methods including nipple stimulation, sexual intercourse, herbal preparations, homeopathic solutions, castor oil, acupressure, acupuncture
Describe the agents for cervical ripening
- Misoprostol (cytotec) vaginally, must wait 4hrs to give oxytocin
- Prostaglandin agents:
- -Dinoprostone (cervidil) inserted vaginally, followed in 30-60 min with oxytocin
- -Dinoprostone gel (Prepidil) vaginally with oxytocin 6-12 hrs after last dose
- Mechanical methods:
- -Laminaria expands from cervical fluid, creating pressure on cervix that releases prostaglandins
- -Foley balloon into cervix puts pressure
- Warmed saline solution thru IUCP by physician to replace the amniotic cushioning for umbilical cord usually achieved by amniotic fluid
- -umbilical cord compression
- -dilution of meconium stained fluid (Research does not support)
- -continuous or one time infusion
- -Continuous monitoring required
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