Unit Eight Normal labor Labor is described as the process by which the fetus, placenta - PowerPoint Presentation

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Unit EightNormal labor

Labor is described as the process by which the fetus, placenta and membranes are expelled through the birth canal. Normal labor occurs at term and is spontaneous in onset with the fetus presenting by the vertex. The process is completed within 18 hours and no complications arise.

PhD in MCH

Dr.

Areefa

SM

Albahri

PhD in MCH

Slide2

Initiation of labor:

The

exact mechanism that initiates labor is unknown.

Theories include the following:

Uterine stretch theory: uterus becomes

stretched

causes a release of prostaglandins.

Prostaglandin + oxytocin cause pressure

on cervix stimulate

more production

of oxytocin).

There

is increased production of prostaglandins by fetal membranes and uterine

decidua as

as pregnancy advances.

In later pregnancy, the fetus produces increased levels of cortisone which inhibit progesterone production from the placenta.

Placental aging and deterioration triggers the initiation of contractions.

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General terms:

Lie: a comparison of the long axis of the fetus with the long axis of the mother. Fetal lie is either, longitudinal, transverse or oblique. In longitudinal lie either the fetal head presents or the buttocks present. In transverse lie, the shoulders present.

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Presentation: the part of the fetus deepest in the birth canal. Presentation may be vertex, face, brow, breech or shoulder.

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Attitude: relationship of fetal parts to each other (normal flexion).

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Position: Position refers to the location of a fixed reference point on the fetal presenting part in relation to a specific quadrant of the maternal pelvis. The presenting part can be right anterior, left anterior, right posterior, and left posterior. These four quadrants designate whether the presenting part is directed toward the front, back, right, or left of the passageway.It is the relationship of landmark on the fetal presenting part to the front (anterior = A) back (posterior = P) or side (transverse = T) of the mothers pelvis. Landmarks on the fetal presenting parts include head = occiput (O) buttocks = sacrum (S), shoulder = scapula or acromion (A), face = chin of mentum (M).

Example: a fetus presenting by the vertex with his

occipit

on the left anterior part of the woman’s pelvis would have his presentation and position described as LOA or lift occiput anterior.

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Factors affecting labor:

•

Powers (physiological forces)

• Passageway (maternal pelvis)

• Passenger (fetus and placenta)

• Passageway _ Passenger and their relationship

(engagement, attitude, position)

• Psychosocial influences (previous experiences, emotional status)

Successful labor and delivery depend on adequate pelvic dimensions, adequate fetal dimensions, presentation and adequate uterine contractions.

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True and false labor contractions

True labor contractions

false labor contractions

Result in progressive cervical dilation and effacement.

Do not result in progressive cervical dilation and effacement.

Occur at regular intervals.

Occur at irregular intervals.

Intervals-between

contractions decrease.

Intervals remain the same or increase.

Intensity increases.

Intensity decrease or remains the same.

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Location mainly in back and abdomen.

Location mainly in groin and abdomen.

Generally intensified by walking.

Generally unaffected by walking.

Not affected by mild sedation.

Generally relived by mild sedation.

Dilation and effacement of the cervix are progressive.

There is no change in the cervix.

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Pre-labor is the term given to the last few weeks of pregnancy

A. Lightening

,

the setting of the fetus in the lower uterine segment occurs 2-3 weeks before the onset of labor in the

primigravida

and later during labor in the multigravida.

1. The

woman’s breathing becomes

easier

2.

Lordosis

of the spine is increased,

3. Frequency

of

micturation

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B. Vaginal

secretions may increase.

C. SHOW

(bloody show

)

Its presence often indicates that labor will begin within 24 to 48 hours.

D. Taking

up of the

cervix.it gradually

merges into the lower uterine segment. The cervix becomes soft and effaced “thinned”. This softening and thinning is called

cervical effacement

E. False

labor contractions may

occur in last weeks of pregnancy.

F. Membranes

may rupture.

G. As

the pregnancy approaches term, most women become more aware

o

f Irregular

contractions called Braxton-Hicks contractions.

Note (regular U C+ CD+ bloody show ) this = onset of true labor women need admission

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Stages of labor

1. The

1

st

stage is that of dilation of the cervix. It begins with regular rhythmic contractions and is complete when the cervix is fully dilated 10

cm.

2. The

2

nd

stage of labor is the expulsion of the fetus. It begins when the cervix is

fully dilated

and is completed when the

baby is completely born

.

3. The

3

rd

stage of labor includes

separation and expulsion of placenta and membranes.

It lasts from the birth of the baby until the placenta and the membranes have been expelled. (

about half an hour

)

4. The

4

th

stage lasts from delivery of the placenta until the postpartum condition of the woman has become stabilized

“usually 1-2 hour after delivery”

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Latent phase: { cervical dilation is 0-3 cm}Begins with the establishment of regular contractions (labor pains). Labor pains are often initially felt as sensations similar to painful menstrual cramping and are usually accompanied by low back pain. Contractions during this phase are typically about 5 minutes apart, last 30 to 45 seconds, and are considered to be mild. Usually, woman is excited about labor and talkative. It takes up to 10-14 hours.

First stage consist of:

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2. Active

phase:

cervical dilation is 4-7 cm.

The active phase of labor is characterized by more active contractions. The contractions become more frequent (

every 3 to 5 minutes), last longer (60 seconds),

and are of a moderate to strong intensity.

While

the length of the active phase is variable,

nulliparous

women generally progress at an average speed of

1 cm of dilation per hour

and multiparas at

1.5 cm of cervical dilation per hour.

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3. Transitional

phase: cervical dilation is 7-10 cm

The transition phase is the most intense phase of labor. Transition is characterized by frequent, strong contractions that occur every 2 to 3 minutes and last 60 to 90 seconds on average.

Other sensations that a woman may feel during transition include rectal pressure, an increased urge to bear down, an increase in bloody show, and spontaneous rupture of the membranes (if they have not already ruptured).

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Mechanism of labor

If the woman’s pelvis is adequate, size and position of the fetus are adequate and uterine contractions are regular and of adequate intensity, the fetus will move through the birth canal.

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Nursing management during labor

Assessment:History taking and baseline data:{refer to your book}Abdominal examVaginal exam

Indications for vaginal examdiagnosis of labor, dilation of the cervixidentification of presentation.To determine whether the head is engaged in case of doubt.Assess ruptured M or to rupture them artificially.To exclude cord prolapsed after rupture of membranes.To assess progress or delay in labor.To apply a fetal scalp electrode.

When VE is

contraindication?

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Assessing uterine contractions(Intensity, Frequency and Duration)

Place fingertips gently on the funds.As contraction begins, tension will be felt under the fingertips. Uterus will become harder, then slowly soften.The intensity may be described as follows:Mild: the uterine muscle is somewhat tense.Moderate: the uterine muscle is moderately firm.Strong: the uterine muscle is so firm that it seems almost board-like.

The frequency

is measured in minutes, represents the time from

the beginning of one contraction

until the

beginning of the next

.

Duration of contraction

is timed from the moment the uterus first begins to tighten until it relaxes again.

When

the cervix becomes completely dilated, the contractions become very strong, last for

60 seconds

and

occur at

2-3

m

inute intervals.

 

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Assessing fetal heart tones

Note location, rate and character.Determine the position, presentation and lie of the fetus.Place the fetal stethoscope on the abdomen over the back or chest of the fetus.Listen and count the beat for one minute.Check the rate before, during, and after a contraction to detect slowing or irregularities (110-160 BPM normal)

Differentiate between FHT and

other

abdominal

sounds by:

1. FHT

, very rapid, somewhat muffled ticking sound

.

3. Maternal

pulse (umbilical arteries) is synchronous with

funic

soufflé.

الصوت السرى او الحبلى

Note: Check

FHR immediately following rupture of the membranes

.(why)

Slide23

Fetal monitoring

The purposes of CFM during labor are:To monitor the progress of a women’s contraction pattern.To monitor the condition of the fetus in response to contractions.Women’s reaction to being monitored varies:Some women are reassured by hearing the continuous fetal heart sound.Some women experience discomfort because of the abdominal straps & their interference with movement as well as difficulty assuming a comfortable position.

External monitoring (indirect):

Separate transducers are secured to the women’s abdomen.

An

ultrasound transducer translates fetal heart sound into electrical signals that are

recorded on a strip

chart.

The ultrasound transducer device should be applied over the abdomen where the sharp fetal heart sound is heard.

The

measurement by external monitoring of the intensity of uterine contractions is not accurate.

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Internal monitoring (direct):A method of recording intrauterine pressure and FHR through internal measurement.More accurate than external monitoring. Note:The membranes must be ruptured.The cervix must be dilated 3-4 cm.The station must be (-2) or lower.Uterine contractions are recorded by means of a catheter placed in uterine cavity behind the presenting part.The catheter filled with distilled water and is connected to an external transducer that converts pressure to electronic signals.Monitor strips record the quality of the uterine contractions and fetal heart patterns simultaneously.

Internal

fetal monitoring is used for

high-risk births

or during a normal birth where the birth

is

having trouble keeping the baby on the monitor or the baby's reaction doesn't look great on the less accurate form of

external fetal monitoring

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Interpretation

:

FHR must be checked initially for rate in the absence of or in between contraction.

A change from the baseline is termed as

fluctuation

and is either

acceleration or deceleration

.

Slide27

Documentation of CTG

the CTG the documentation of the pattern should include: woman’s name, date and timeestimated gestational age, clinical indications for performing the FHR pattern,maternal pulse rate. The outcome of the FHR pattern should be documented both on the CTG and in the woman’s medical records at least every ½ hourly throughout labour.

27

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FHR evaluation

determine the riskContractions baseline rate variabilityaccelerationsdecelerations overall assessment (followed by a management plan)

28

Slide29

Who should have continuous electronic FHR monitoring?

Antenatal risk factorsPrematurityPre-eclampsia/eclampsiaDiabetesGrowth restrictionNon-reassuring antenatal fetal welfare assessmentMultiple pregnancyMalpresentation

29

Slide30

Who should be have continuous electronic FHR monitoring?

Intrapartum risk factorsSyntocinonMeconiumEpiduralSuspicious FHR on auscultationProlonged rupture of the membranesPrematurityPrevious C/S

30

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Practice Recommendations for intermittent auscultation

Healthy women with uncomplicated labour Pinards/Doppler recommended every 15mins 1st stage every 5mins 2nd stageContinuous EFM is recommended if:Baseline < 110 or >160bpm; Decelerations or intrapartum risk factors develop

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Baseline rate

Normal = 110 – 160bpmBradycardia (moderate) = 100 – 109bpmBradycardia (abnormal) = < 100 bpmTachycardia (moderate) = 161 – 180 bpmTachycardia (abnormal) = >180 bpm (RCOG)

32

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Variability

Greater than 5bpm and less than 25bpmIncreased variability is often seen following an acute hypoxic event. Should settle after about 10 mins when the fetus returns to normal O2 levels

33

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Acceleration or deceleration of the FHR are due to:uterine pressure applied directly to the fetal head and / or umbilical cord.Uterine pressure applied directly to the intervillous space ("space between the villi containing the vessels" of the mother and the embryo . ..) which leads to decrease blood flow.

Slide35

An acceleration is defined as an increase in the FHR of 15 bpm above the fetal heart baseline that lasts for at least 15 to 30 seconds. Accelerations are considered a sign of fetal well-being when they accompany fetal movement.Thus, when a fetus is active in utero, accelerations are normally present. accelerations are often noted as a response to the contraction.Limited acceleration during sleeping fetus.

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Deceleration :Early Deceleration.Begins near the onset of contractionLowest level of FHR occurs at the peak of the intrauterine pressure (contraction).FHR does not fall below 100 BPM.Not usually cause change in acid-base balance.Caused by fetal head pressure (which cause vagal stimulation which decrease in HR)May occur during vaginal examinationsuterine contractions, and during placement of the internal mode of fetal monitoring.Need no intervention.

Early decelerations.

Bottom

. Uterine contractions.

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Late deceleration:Begins later in contracting phase of uterus (as the contraction reaches its peak) and resolved when the contraction ends.Usually less than 90 seconds in duration.Passage of meconium may occur.Associated with progressive fetal hypoxia and acidosis.Due to acute uteroplacental insufficiency as a result of a decreased blood flow from the uterus to the placenta results in fetal hypoxia and late decelerations).Should be reported immediately.

Late decelerations.

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Late deceleration can be avoided by:

a) Careful maintenance of maternal pressure within normal limits

b) Careful infusion of

oxytocins

and anesthetics .

Late deceleration can be modified by :

a) Discontinue oxytocin if being given .

b) Chang the woman's position to the left side

c) Administer oxygen and IV fluid

d) Obtain fetal blood sample to measure degree of hypoxia and acidosis

e) If persist, labor may be terminated by Cesarean or Forceps delivery

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Variable deceleration Decelerations are variable in terms of their onset, frequency, duration, and intensity.Due to umbilical cord compressionNon uniform and has no relation to contractionsIn severe deceleration, FHR may fall by 70 BPM and last longer than 60 seconds. Usually relieved by changing position of the woman to relieve pressure on the cord When sever cord prolapse should be suspected

Slide40

Tachycardia is generally defined as a sustained baseline fetal heart rate greater than 160 beats per minute for a duration of 10 minutes or longer. A number of conditions are associated with fetal tachycardia:Fetal hypoxia Maternal feverMaternal medicationsInfectionFetal anemiaMaternal hyperthyroidism

Bradycardia

is defined as a

baseline

FHR of less than 110 to 120

bpm

.

Fetal

bradycardia

may be associated with:

• Late hypoxia

• Medications: (e.g.,

propanolol

)

• Maternal hypotension

• Prolonged umbilical cord compression

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The stages of labor1st stage of labor

First stage divided into 3 phases

Latent

phase (0-3cm)

.

contractions

(

usually 5-30 minutes apart, lasting 20-40 second), fetal heart sounds every1-2 hours, temperature every

4 hours unless elevated.

Provide clear liquids if permitted

Allow the woman to

walk.

Evaluate and teach breathing techniques helpful in coping with active and transitional phase of the 1

st

stage and breathing

Provide support for the

woman's care such as providing back massage and timing of contractions.

Provide privacy for

in the periods

of giving care.

Encourage the woman to void approximately every 2 hours to keep bladder empty

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Active phase (4-7 cm)

Contractions are usually 2-5 minutes apart, lasting 30-50 seconds

Monitor progress of labor, take and record vital signs, Contractions and fetal heart sounds every 30 minutes

Be aware that the woman may begin to feel unable to cope with discomfort and may begin to lose control

breathing

and relaxation techniques with each contraction

Provide comfort measures:

Side-lying position is usually more

comfortable

Provide

sacral hand pressure and backrest

Change wet or soiled linen

Assist with mouth care

Continue

to provide encouragement and information

Administer prescribed analgesia as prescribed

Maintain hydration and glucose level of woman. Low glucose level decrease intensity of contractions (I.V) fluid may be necessary

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Transitional phase (7-10cm).

Contractions are usually 2-3 minutes apart, lasting 50-90 seconds

Generally

it is the most difficult phase of the 1

st

stage

Bloody show increases

Nausea

and vomiting may occur because of reflex action as the cervix stretches and begins to retract over the fetal head

Woman may

be restless

and cry during feelings

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Nursing Interventions in the first stage:

Monitor

progress of labor, vital signs, contractions and fetal heart sounds every15 minutes

Assist with controlled breathing as contractions occur

Discourage the woman from bearing down until cervical dilatation is complete

Encourage the women to rest between contractions to conserve energy

Provide concise and brief explanations because woman is irritable

Remind the woman that labor is nearing its end

Prepare the woman for movement to the delivery room

Slide46

2nd and 3rd stage of labor

Characteristics:

Full cervical dilation occurs, infant is delivered

Usually

primigravida

has an average of 20 contraction and multigravida an average of 10 contraction

Slide47

Nursing Interventions

Monitor

FHR, contractions and blood pressure every 5 minutes

Encourage pushing

, only with contractions using abdominal muscles

If the partner or support person is present, have him to support woman and see birth if desired

Cleanse vulva and

perineal

area

Check equipment needed for infant resuscitation

Keep the

woman

informed of progress of delivery

The woman may need to be catheterized,

if

bladder is full

When the

vulvovaginal

ring encircles the head, an episiotomy may be performed to prevent tearing of the perineum

Slide48

Episiotomy is a surgical incision of the perineum that is performed to enlarge the vaginal orifice during the second stage of labor.

Continue Nursing Intervention

When

the baby is delivered, the infant is

put in mother abdomen

Placenta usually separates and delivered within 15-20 minutes following delivery of the baby.

Vaginal canal and cervix are inspected for lacerations or injury,

The

woman’s

perineal

area is cleansed and a sterile

perineal

pad applied.

As

the placenta separates from the uterine wall, it is important that the uterus continues to contract.

attachment

site. Failure of the uterus to contract adequately with separation of the placenta can result in excessive

blood loss or hemorrhage.

To enhance the uterine contractions after expulsion of the placenta, oxytocin is often given (IV or IM).

Once the placenta has been delivered, the nurse carefully examines it to ensure that all cotyledons are intact.

If

any part of the placenta is missing, the nurse immediately reports this finding to the attending

physician.

Slide49

4

th

stage of labor

Considered to be the stage of recovery period but in the same time it is a critical period for the mother and the newborn

It is the first

two hours post-birth

, the mother starts readjustment to the non-pregnant state and body systems begin to stabilize

The primary danger for the mother is hemorrhage

The safety of the mother depends on frequent assessment and timely interventions of alert nurses

During is the first hour for physical assessment, all factors except temperature are assessed every 15 minutes then every 30 minutes during the second hour

Slide50

Factors to be assessed:Vital SignFundus: firm and 2 cm below or at level of umbilicus, but if it was soft, message is done until firm BladderEmotional status Lochia: if blood comes in spurts, cervical tear is suspected Perineum: assess sutures of episiotomy Discomfort (after pain): as a result of uterine contraction

Slide51

Potential for hemorrhage related to uterine atony and trauma

The fundus remains firm with gentle massage Massaging expels blood and clots (uterus contract)If uterus doesn't respond and bleeding continues, I.V Pitocin is administered Lochia is bright red (scant, moderate, heavy)Assess the amount of bleeding by checking the perineal pads and under buttocks

Note :

Saturated pad (tail to tail) =100ml blood

Loss of 100 ml blood/15 min is considered heavy

Vital signs every 15 minutes

Notify the physician

Slide52

For Episiotomy and Hemorrhoids:

Encourage side lying positionApply ice packs for 2 hoursAdminister analgesics as prescribed Encourage self- relaxation techniques

Slide53

Complications of labor and birth 

Premature Rupture of Membranes (PROM)Is the spontaneous rupture of fetal membranes one hour or more before the onset of labor.Incidence: 10% of all pregnancies.Causes: remains unknown in most cases.

Risk factors:PolyhydaminosCerculageAmniocentesisPlacental abruption.InfectionMore common in twins gestation.Seldom associated with trauma

Complications:

Preterm delivery.

Maternal or fetal infections:

Chorioamniositis

endometrits

clinically persisting after delivery.

Fetal distress

Umbilical prolapsed more common in cases of PROM.

Increase rate of stillbirths

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Evaluating the patient with PROM

Sterile speculum examination:-Visualize pool of fluid in vaginal fornix-Leakage of fluid through cervix.pH of amniotic fluid is 7.1 to 7.3Normal vaginal pH is 4.5 to 6Nitrazine paper turns blue at pH > 6.5Cervical dilation is assessed.Observe for prolapsed fetal part or umbilical cord.Collection of fluid for lung maturity Ultrasound is a final confirmatory step in some cases.Establish gestational age and fetal maturity Rule out infection& fetal distress.continuous fetal heart tone monitoring.

Management

and interventions:

Term patients:

Immediate induction is suggested.

Preterm patients:

Survival rate

after

26 weeks is close to 50%.

If

less

than 34 weeks, efforts are directed toward maintaining pregnancy.

Tocolytic

therapy (

terbutaline

)

Antibiotics

therapy

Nurse monitors vital signs

emotional

support are provided

prepares the mother for delivery, cesarean birth, a preterm neonate and potential loss of the fetus.

Slide55

Preterm laborIs defined as rhythmic uterine contractions that produce cervical changes prior to completion of 37 weeks gestation.Incidence:7% to 10% of infants are born prematurely.Responsible for 75% of prenatal mortality and about 50% of neurological deficits.

Etiology:

Upper

and lower extremes of age.

Lower

socioeconomical

status.

Smoking

and drug abuse.

Prolonged periods of standing.

Fatigue and long hours at work

.

Reproductive history

:

Previous preterm delivery.

Incompetent cervix.

Spontaneous or induced abortion.

Uterine anomalies e.g.

leiomyomata

.

- Multiple gestations.

-

Premature

rupture of membranes (most common cause).

Infection.

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Assessment:Cervical dilation.Membranes: ruptured or not.Presences of sever preeclampsia and hemorrhage.Ultrasonography: to determine fetal gestational age, condition and weight.

Management and intervention:

Special prenatal care for high risk women.

Frequent visits for weeks 22 to32.

Urine culture at 24 weeks.

Vaginal examination for

pH.

Education on nutrition and preterm labor.

Observe Signs

and symptom

reinforced such as :

1. Increased

or change in vaginal discharge.

2. Uterine

contractions.

3. Vaginal

bleeding or leaking fluid.

Provide Bed

rest and hydration

:

Continuous monitoring.

Tocolytics

:

Slide57

Cont, management

- Now most frequently used agents are magnesium sulfate and beta mimetic agents → acts on β

2

receptors on myometrium.

- Maternal transport:

tocolytic

therapy may improve outcomes by delaying delivery enough to facilitate transport.

Note : labor is not stopped if one or more of the following are present "exclusion criteria for

tocolytic

therapy":

1. Advanced cervical dilation, usually > 6 cm.

2. PROM.

3. Abruption.

4. Fetal distresses or death.

5. Major fetal anomalies incompatible with life.

6. PIH with HELLP syndrome.

Fetal maturation therapy:

glucocorticord

therapy.

Slide58

Nursing care:

-

Placed on bed rest, lying on her side.

- Uterine contractions are evaluated and monitored every 1-2 hr.

- Continuous monitoring of FHR.

- Cervical consistency, dilation and effacement are evaluated.

- Symptoms are evaluated for progress “increasing or decreasing".

- I.V fluids started, intake and output are monitored.

Once contraction have been stopped and women's condition has stabilized, she may be discharged and the following done to prevent subsequent occurrence:

- Bed rest

maintained.& vitamins

supplement, especially vitamin C.

- Usual activity level is evaluated and restricted if necessary.

- Chronic illnesses are monitored closely, acute illnesses are treated promptly.

- Oral medications may be continued at home.

- Prenatal visits are made weekly for remainder pregnancy

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Postdate (post term pregnancy or prolonged pregnancy)

Duration

of pregnancy: 280 days or 40 weeks from the first day of the LMP or 266 days from ovulation, based on 28 day cycle.

Post term:

pregnancy lasting more than 2 weeks beyond the expected date of delivery “after day 294, 42 completed weeks or more"

Etiology

:

most

frequent cause is inaccurate dating of pregnancy.

The exact cause of

postterm

pregnancy is unknown. However, a possible cause may be related to a deficiency of placental estrogen and the continued secretion of progesterone.

Low

levels of estrogen may result in a decrease in prostaglandin

& reduced

formation

of

myometrial

oxytocin receptors.

Slide60

Rare causes:

- Fetal anencephaly, adrenal hypoplasia.

- Lake of cervical prostaglandin production.

Maternal problems:

1. Emotional stress.

2. Potential for delivery trauma.

3. Hemorrhage, infection, and labor abnormalities

.

Slide61

Infant problems : much more serious than those for this mother.

1

.

Oligohydramnios

associated with

cord compression, acute fetal hypoxia and

SID.

2.

Macrosomia

birth trauma, obstructive labor, shoulder

dystocia

.

 

3. Meconium aspiration

due to thick

meconium

as a result of

oligohydramnios

.

4.

Intraprtum

fetal distress.

5.

Dysmaturity

: at 37 weeks, there is no further growth of the placenta. It ages rapidly past the fortieth week of gestation; it becomes inefficient and cannot adequately support the

fetus

6. Neonatal problems may include asphyxia, meconium aspiration syndrome, hypoglycemia, polycythemia, respiratory distress, and

dysmaturity

syndrome.

Slide62

Management:

Weekly vaginal examination, plan induction when cervix is favorable.

Antepartum fetal heart monitoring, non stress test, ultrasound scans.

Induction of labor, prostaglandins or oxytocin, forceps- or vacuum-assisted birth and cesarean birth

Fetal distress emergency cesarean section sometimes required.

Slide63

Hypotonic uterine contraction (inertia)

Hypotonic

labor is defined as less than 3 contractions of mild to moderate intensity occurring in a 10 minutes period during the active phase of labor.

The intrauterine pressure (IUP) is insufficient for the progression of cervical effacement and dilation.

Cervical dilation and descent of fetus slow greatly or stop.

Slide64

Etiology:Such labor occurs when uterine fibers are overstretched from large baby, twins, hydramnios, or multiparity.May also be caused by administration of sedations or narcotics.Bowel or bladder distention.

Slide65

Potential maternal effects:

- Exhaustion.

Postpartum

hemorrhage.

- Stress and psychological trauma.

Infection

.

Potential fetal effects:

- Fetal sepsis (Infection).

- Fetal and neonatal death.

Slide66

Medical management:

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 can decrease the need for pharmacological agents for pain.

Oxytocic stimulation

of labor or prostaglandin stimulation.

Slide67

Nursing intervention:

Pelvis is reevaluated for size.

IV fluids are provided to maintain hydration and electrolyte balance.

Oxytocin administration

is started if pelvic size is adequate, fetal position and presentation is normal.

Monitor FHR and contractions, if contractions last more than 60-70 seconds, decrease or stop infusion to prevent rupture of uterus and premature separation of the placenta and fetal hypoxia.

Observe IV drip, be certain that infusion is running at the prescribed rate.

Report any maternal or fetal distress immediately.

Amniotomy

may be performed to augment labor.

Use anxiety-reducing measures to promote psychological and emotional status.

Slide68

Hypertonic uterine contraction

usually

occurs in the latent phase of labor, with an increase in frequency of contractions and a decrease in their intensity.

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.

Contraction

may be uncoordinated and involve only portions of the uterus.

Usually occurs before 4 cm dilation. The cause is not yet known, may be related to fear or tension.

Slide69

Potential maternal causes:

Maternal

anxiety

(

Primiparous

labor, Loss of control, Sexual abuse,

Lack of support

, Cultural differences, Fear of pain)

Potential fetal causes:

occiput–posterior malposition

Slide70

Medical management:

Analgesic

(morphine,

meperdine

) if membranes are not ruptured and

fetalopelvic

disproportion isn't present.

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 occiput–posterior position, the major goal of care is to facilitate rotation of the fetal head into a more favorable position (

walk and change positions frequently).

Slide71

Nursing intervention:

Provide bed rest with end of sedatives to promote relaxation and reduce pain.

Provide fluids to maintain hydration and electrolyte balance.

Observe for normal contractions when woman awakens.

Oxytocin is not administered; it will increase the abnormal labor pattern.

Check intake and output every 2 hr.

Monitor vital signs and FHR.

If the condition is prolonged, check for CPD and

malpresentation

, if excluded,

amniotomy

and oxytocin infusion may be instituted.

Reduce anxiety; give psychological and emotional support measures.

Slide72

Uterine ruptureis a spontaneous or traumatic rupture of the uterus.Causes:Rupture of the scar from a previous cesarean delivery or hystrotomy.Uterine traumaCongenital uterine anomaly.Prolonged or obstructed labor.Forced delivery of fetus with abnormalities e.g. hydrocephalus.Internal or external version.Application of forceps and extraction before cervical os has completely dilated.Injurious use of oxytocin.Excessive manual pressure applied to the fundus during delivery.

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Clinical manifestation:

1.

Complete rupture:

- Sudden sharp abdominal pain during contractions.

- Abdominal tenderness. – Cessation of contractions.

- Bleeding into abdominal cavity and sometimes into vagina.

- Fetus easily palpated, fetal heart tones cease.

- Signs of shock.

2. Incomplete rupture:

- Develops over a period of few hours.

- Abdominal pain during contractions.

- Contractions continue, but cervix fails to dilate.

- Vaginal bleeding may be present.

- Tachycardia, pale skin.

- Loss of heart tones.

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Management and nursing intervention:

Emergency

laparotomy is performed with complete rupture, usually the uterus is removed and attempts are made to save the baby

.

Administer IV fluids and blood as directed.

Administer oxygen to the woman.

Prepare the woman for emergency surgery.

Monitor maternal

&

fetal vital signs until surgery begins.

Uterus may be repaired if rupture is not extensive, if extensive hysterectomy is necessary.

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Amniotic fluid embolism.

Is

the accidental infusion of amniotic fluid in to the mother's blood stream under pressure from the contracting uterus.

Amniotic

fluid containing fetal

vernix

, lanugo, meconium, and mucus enters maternal blood

through

defect's in to the placental attachment, these particles become emboli in the mother’s general circulation causing acute respiratory, circulatory collapse, hemorrhage and

corpulmonale

as they block the vessels of her lungs.

These particles stimulate abnormal coagulating, initiating DIC.

Amniotic fluid embolism is rare and usually fatal (mortality rate is as high as 80% for mothers & approximately 50% of neonates)

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Clinical manifestations:

Sudden

dyspnea and chest pain.

cyanosis.

tachycardia.

- Pulmonary edema.

Prolonged

shock due to:

1. Anaphylaxis, which cause vascular collapse.

2. Uterine bleeding with development of

hypofibrinogenemia

.

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Management and nursing intervention:

Emergency measures are instituted immediately including, cardiopulmonary resuscitation (CPR).

1. Improving tissue perfusion and cardiopulmonary function.

2. Administer O

2

as soon as possible, when situation is recognized.

3. Provide assisted ventilation.

4. Maintaining fluid volume and correction of DIC.

5. Administer fresh whole blood and fibrinogen.

6. Administer IV fluids and plasma.

7. Provide continuous monitoring of maternal and fetal status.

8. Delivery of fetus.

9. Since fetus is in great danger, cesarean approach is used.

10. Care for the neonate and provide family members with comfort and information about the status of mother and infant.

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Prolapsed Umbilical CordUmbilical cord prolapse occurs when a loop of the umbilical cord slips down below the presenting part of the fetus.

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Types

Occult

prolapse

(hidden; not visible), occurs at any time during labor whether or not the membranes have ruptured—the cord lies beside the presenting part in the pelvic inlet.

Complete 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.

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Causes:

Rupture of membranes

, when the presenting part is

not engaged in

the pelvis.

More common

in shoulder & foot presentation

.

Prematurely:

As small

fetus allows more space around presenting part.

Hydramnios

:

greater amount of fluid to be related with greater force when membranes rupture.

Contracted pelvis.

Placenta

previa

.

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Clinical Manifestation:

Cord may be seen protruding from vagina, or can be palpated in the vaginal canal cervix

.

Signs of fetal distress: the cord is compressed between the presenting part and bony pelvis.

If cord is exposed to cold room air, there may be reflex constriction of umbilical vessels, restricting oxygen flow to fetus

.

Fetal heart rate pattern may be irregular with periodic fetal

bradycardia

.

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Management

Maintaining oxygen supply to fetus:

-all

women whose membranes have ruptured should remain on bed rest.

-At the time of spontaneous rupture or

amniotomy

,

FHR is assessed continuously, if

bradycardia

is noticed, assess for cord prolapse.

-Place the women in recovery or knee-chest position.

-Administer oxygen to the women.

-Place sterile gloved hand in vagina and push the fetal head up ward to relief compression of the cord.

-Prepare of immediate vaginal delivery if cervix is dilated.

-Prepare of immediate cesarean delivery if cervix is not deleted.

-In home situation, cover-protruding cord with clean wet dressing. Elevate the woman's hips and transports to hospital immediately.

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Uterine Inversion

Uterine inversion

(uterus is turned inside out) is a rare but potentially life-threatening complication.

Possible causes:

Most common cause is excessive

pulling on the umbilical

cord in an attempt to hasten the third stage of delivery.

Other

contributing factors include

vigorous fundal pressure

,

uterine

atony

, and abnormally adherent placental tissue.

Clinical Manifestations:

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.

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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.

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Induction of Labor

Is the

initiation of uterine contractions before their spontaneous onset.

Is the use of physical or chemical stimulants to initiate or intensify uterine contractions.

The need for initiating labor may arise from maternal or fetal sources. E.g. PIH,

post-term

pregnancy, D.M, PROM, I.U.F.D (intra Uterine Fetal death).

Elective induction may be indicated for the woman who has a history of precipitate labor to avoid unexpected out of hospital birth.

There are a number of medically approved methods to induce labor; they include chemical induction with prostaglandins, oxytocin and mechanical as rupture of membranes.

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Prostaglandins

A prostaglandin gel for local application to the cervix has been formulated to soften the cervix and induce labor

.

For those women whose cervix is unfavorable, induction using PG

E

is more effective than using oxytocin.

routine assessment for,

dilation of cervix

is required.

A 30 minutes electronic monitoring of FHR and uterine contractions is done to establish base line data.

The physician instills 0.5 mg of PG

E

intracervically

using a plastic catheter. The catheter is then removed.

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The woman remains in bed for 30 minutes, then may ambulate.

FHR, BP and pulse are monitored at least every 30 minutes.

Contractions usually begins 1/2 hour after administration of gel, the time of contraction is recorded.

An

amniotomy

is performed at 4 cm of cervical dilation and internal fetal monitoring is applied.

Progress of labor is recorded.

Any hypertonic contractions of the uterus are reported immediately.

If the woman doesn`t deliver within 24 hours, the cervix is reassessed and an induction using oxytocin is done if indicated.

Because prostaglandin administration is effective, free of side effects and non invasive, some authorities believe it will replace

amniotomy

and oxytocin as the method of choice for induction of labor.

The woman is kept informed of the progress of labor

.

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Oxytocin

May be used either to induce the labor process or to augment a labor that is progressing slowly because of inadequate uterine contraction, or to assess fetal response to the stress of contractions.

Indications

:

Prolonged pregnancy.

Preterm delivery in diabetic mother.

Severe Preeclampsia,

Abruptio

placenta or I.U.F.D.

Multigravida with a history of precipitate labor.

Prolonged rupture of membrane.

Management of abortions.

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Contraindications:

Fetopelvic

disproportion .

Fetal distress.

Previous uterine surgery.

Over distended uterus e.g. multiple pregnancy.

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Hazards:

Maternal

: titanic contractions,

Abruptio

placenta, Postpartum hemorrhage, infection, DIC, Amniotic fluid embolism, anxiety and fear.

Fetal

: Asphyxia, Hypoxia, physical injury and Prematurity.

10 IU of oxytocin is added to 1L of 5% dextrose or saline solution.

Initial dose 2

milliunits

/minute via constant infusion pump.

Dose is increased every 15-20 minutes until dose is 20

milliunits

per minute.

Monitor the woman's BP, P, respiratory rate, contractions and FHR every 15 minutes.

If FHR indicate distress or if contractions last 70 seconds or more, reduce or discontinue administration immediately.

Increase IV solution without oxytocin, give O

2

, turn on her left side and call the physician.

Satisfactory labor has usually been initiated when the woman has 3 contractions in 10 minutes.

Reduce anxiety.

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Amniotomy

Transcervical

amniotomy

or artificial rupture of membranes can be used to stimulate labor.

Simple

rupture of the membranes using sharp instrument passes over a finger into the cervix will allow the discharge of amniotic fluid.

Procedure is explained to the woman, FHR recorded.

Note and record amount and quality of fluid (clear, color, bloody, meconium…).

Artificial rupture of the membranes is often done to augment labor already in progress, since the membranes serve as a barrier against infection.

Delivery is usually accomplished soon after the membranes have been ruptured artificially.

Some obstetricians prefer to first stimulate the uterus with IV oxytocin and as soon as good contractions are evident, rupture the membranes. Others prefer merely to rupture the membranes.

Reduce anxiety.

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