LABOR AND BIRTH AT RISK (Preterm, Postterm Labour, Preterm Premature Rupture of Membranes, Distocia)

LABOR AND BIRTH AT RISK (Preterm, Postterm Labour, Preterm Premature Rupture of Membranes, Distocia). Nursing Care during Labour and delivery with risk Factors.

Prepared by Ass. Prof. N. Petrenko, MD, PhD



• Differentiate between preterm birth and low birth weight.

• Identify the risk factors for preterm labor.

• Discuss current interventions to prevent preterm birth.

• Discuss the use of tocolytics and antenatal glucocorticoids in preterm labor and birth.

• Examine the effects of prescribed bed rest on pregnant women and their families.

Discuss the criteria for evaluating the nursing care of women experiencing labor and birth complications.

Describe the care of a woman experiencing postterm pregnancy.



amniotic fluid embolism (AFE) Embolism resulting from amniotic fluid entering the maternal bloodstream during labor and birth after rupture of membranes; often fatal to the woman if it is a pulmonary embolism

antenatal glucocorticoids Medications administered to the mother for the purpose of accelerating fetal lung maturity when there is increased risk for preterm birth between 24 and 34 weeks of gestation

augmentation of labor Stimulation of ineffective uterine contractions after labor has started spontaneously but is not progressing satisfactorily

Bishop score Rating system to evaluate inducibility (ripeness) of the cervix; a higher score increases the likelihood of a successful induction of labor

cephalopelvic disproportion (CPD) Condition in which the infant's head is of such a shape, size, or position that it cannot pass through the mother's pelvis or the maternal pelvis is too small, abnormally shaped, or deformed to allow the passage of a fetus of average size

cesarean birth Birth of a fetus by an incision through the abdominal wall and uterus

chorioamnionitis Inflammatory reaction in fetal membranes to bacteria or viruses in the amniotic fluid, which then become infiltrated with polymorphonuclear leukocytes

dysfunctional labor Abnormal uterine contractions that prevent normal progress of cervical dilation, effacement, or descent

dystocia Prolonged, painful, or otherwise difficult birth caused by various conditions associated with the five factors affecting labor (powers, passage, passenger, maternal position, and maternal emotions)

external cephalic version (ECV) Turning of the fetus to a vertex presentation by external exertion of pressure on the fetus through the maternal


forceps-assisted birth Vaginal birth in which forceps (i.e., curved-bladed instruments) are used to assist in the birth of the fetal head

hypertonic uterine dysfunction Uncoordinated, painful, frequent uterine contractions that do not cause cervical dilation and effacement; primary dysfunctional labor

hypotonic uterine dysfunction Weak, ineffective uterine contractions usually occurring in the active phase of labor; often related to cephalopelvic disproportion or malposition of the fetus; secondary uterine inertia

oxytocin Hormone produced by the posterior pituitary gland that stimulates uterine contractions and the release of milk in the mammary glands (let-down reflex); oxytocics are medications that mimic the uterine stimulating action of oxytocin

postterm pregnancy Pregnancy prolonged past 42 weeks of gestation

precipitous labor Rapid or sudden labor lasting less than 3 hours from the onset of uterine contractions to complete birth of the fetus

premature rupture of membranes (PROM) Rupture of the amniotic sac and leakage of amniotic fluid beginning at least 1 hour before the onset of labor at any gestational age

preterm birth Birth occurring before the completion of 37 weeks of gestation

preterm labor Cervical changes and uterine contractions occurring between 20 weeks and 37 weeks of pregnancy

preterm premature rupture of membranes (PPROM) PROM that occurs before 37 weeks of gestation

prolapse of the umbilical cord Protrusion of the umbilical cord in advance of the presenting part

shoulder dystocia Condition in which the head is born but the anterior shoulder cannot pass under the pubic arch

therapeutic rest Administration of analgesics and implementation of comfort/relaxation measures to decrease pain and induce rest for management of hypertonic uterine dysfunction

tocolytics Medications used to suppress uterine activity and relax the uterus in cases of hyperstimulation or preterm labor

trial of labor (TOL) Period of observation to determine whether a laboring woman is likely to be successful in progressing to a vaginal birth

vacuum-assisted birth Birth involving attachment of a vacuum cap to the fetal head (occiput) and applying negative pressure to assist in birth of the fetus

vaginal birth after cesarean (VBAC) Giving birth vaginally after having had a previous cesarean birth



When complications arise during labor and birth, risk of perinatal morbidity and mortality increases. Some complications are anticipated, especially if the mother is identified as high risk during the antepartum period; others are  unexpected or unforeseen. The woman, her family, and the obstetric team can feel devastated when things go wrong. Nurses must recognize these feelings if they are to provide effective support. It is crucial for nurses to understand the normal birth process to prevent and detect deviations from normal labor and birth and to implement nursing measures when complications arise. Optimal care of the laboring woman, fetus, and family experiencing complications is possible only when the nurse and other members of the obstetric team use their knowledge and skills in a concerted effort to provide care. This chapter focuses on the problems of preterm labor and birth, dystocia, and postterm pregnancy and obstetric emergencies.


Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy. Preterm birth is any birth that occurs before the completion of 37 weeks of pregnancy (American College of Obstetricians and Gynecologists & American Academy of Pediatrics, 1997). Preterm labor and birth are the most serious complications of pregnancy because they lead to approximately 90% of all neonatal deaths, with more than 75% of these deaths occurring in infants born at fewer than 32 weeks of gestation. Despite decreasing infant mortality rates in the United States, preterm birthrates have continued to rise. Preterm birth is the second leading cause of infant death. In 1999 the preterm birthrate for all races in the United States was 11.8%, having steadily risen from 9.4% in 1981 (March of Dimes, 1997; Ventura et al., 2001).



Although they have distinctly different meanings, the terms preterm birth and low birth weight are often used interchangeably. Preterm birth describes length of gestation (i.e., less than 37 weeks), whereas low birth weight describes only weight at the time of birth (i.e., 2500 g or less). Low birth weight is far easier to measure than preterm birth, and thus in many settings and publications, low birth weight has been used as a substitute term for preterm birth. Preterm birth, however, is a more dangerous health condition for an infant because length of time in the uterus  correlates with immaturity of body systems. Low-birth-weight babies can be, but are not necessarily, preterm; low birth weight can be caused by conditions other than preterm birth, such as intrauterine growth restriction (IUGR), a condition of fetal undergrowth not necessarily correlated with initiation of labor.

The incidence of preterm birth in the United States varies according to race. The 1999 rate for African-Americans was 17.5%, whereas the rate for Hispanics was 11.4% and for Caucasians was 10.7%. Anecdotal evidence suggests that sociodemographics may play a part in this difference among races. Preterm birthrates are higher among socially disadvantaged populations, including minorities, women with low levels of education, and women who receive late or no prenatal care (Ventura et al., 2001).



The known risk factors for preterm birth are shown in Box 1. Using these risk factors, researchers have tried to determine which women might go into labor prematurely. Risk assessment schema were developed and risk scoring systems were used (Collaborative Group on Preterm Birth Prevention, 1993). None of these risk scoring systems has resulted in lowering the preterm birthrate in the United States, however, because at least 50% of all women who ultimately give birth prematurely have no identifiable risk factors. Programs aimed at decreasing preterm birthrates must include women labeled as "high risk for preterm birth" and women with no identifiable risk factors. Unless all women are included in prevention efforts that begin in the first trimester, a widespread reduction of preterm birthrates cannot be expected (Maloni, 2000).


BOX 1 Risk Factors for Preterm Labor


• Nonwhite race

• Age (<17, >35)

• Low socioeconomic status

• Unmarried

• Less than high school education


• Previous preterm labor or birth

• Second-trimester abortion (more than two spontaneous or therapeutic); still births

• Grand multiparity; short interval between pregnancies <1 year since last birth); family history of preterm labor and birth

• Progesterone deficiency

• Uterine anomalies or fibroids; uterine irritability

• Cervical incompetence, trauma, shortened length

• Exposure to DES or other toxic substances

• Medical diseases (e.g., diabetes, hypertension, anemia)

• Small stature (< 119 cm in height; < 45.5 kg or underweight for height)

• Current pregnancy risks:

• Multifetal pregnancy

• Hydramnios

• Bleeding

• Placental problems (e.g., placenta previa, abruption placentae)

• Infections (e.g., pyelonephritis, recurrent urinary tract infections, asymptomatic bacteriuria, bacterial vaginosis, chorioamnionitis)

• Pregnancy-induced hypertension

• Premature rupture of the membranes

• Fetal anomalies

• Inadequate plasma volume expansion; anemia


• Poor nutrition; weight loss or low weight gain

• Smoking (>10 cigarettes a day)

• Substance abuse (e.g., alcohol; illicit drugs, especially cocaine)

• Inadequate prenatal care

• Commutes of more than 1V2 hours each way

• Excessive physical activity (heavy physical work, prolonged standing, heavy lifting, young child care)

• Excessive lifestyle stressors


Biochemical markers

The two most common biochemical markers used in an effort to predict who might experience preterm labor are fetal fibronectin and salivary estriol. Fetal fibronectins are glycoproteins found in plasma and produced during fetal life. They appear in the cervical canal early in pregnancy, and then again in late pregnancy. Their appearance between 24 and 34 weeks of gestation could predict preterm labor. The negative predictive value of fetal fibronectins is high (up to 95%). The positive predictive value of the fetal fibronectin test is lower (25% to 40%) (Moore, 1999). This means that it may be possible to predict who will not go into preterm labor, but not who will. The test is done during a vaginal examination.

Salivary estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Specimens of salivary estriol are collected by the woman in the home; the testing is done every 2 weeks for approximately 10 weeks. This marker also has a high negative predictive value (98%) and a lower positive predictive value (7% to 25%) (Moore, 1999).


Endocervical length

Some studies have suggested that a shortened cervix precedes preterm labor and can be determined by ultrasound measurement (Crane et al., 1997). A shortened cervical length of less than 30 mm in a singleton pregnancy can predict some instances of preterm labor. When a woman has a short cervix combined with a positive fetal fibronectin result, her risk for spontaneous preterm birth is substantially higher than for women positive for only one marker or none at all (Goldenberg et al., 2000).


Causes of preterm labor and birth

The cause of preterm labor is unknown and is assumed to be multifactorial (Goldenberg & Rouse, 1998; Maloni, 2000) (Box 2). Infection is thought to be a major etiologic factor in some preterm labors. When cervical, vaginal, or urinary tract infections are present, the risk of preterm birth is increased (Box 3). Thus early, continuous, and comprehensive prenatal care, which can detect and treat infection, is essential in dealing with this aspect of preterm birth prevention.


BOX 2 Multifactorial Etiology of Preterm Labor and Birth



Substance use (alcohol or illegal drugs)

Poor nutrition


Short interpregnancy interval

Sexual activity


Young or old age

Previous preterm birth

Short stature

Short cervix

Uterine anomalies

Diethylstilbestrol exposure

Prematurely dilated cervix

Low prepregnancy weight



Low socioeconomic status

Victim of domestic violence


Inadequate support systems


Uterine irritability

Multiple gestation

Late or no prenatal care

Preterm premature rupture of membranes



Catecholamine release

Decreased progesterone production

Decidual cell disruption

Prostaglandin synthesis

Cytokine release


BOX 3 Infections and Risk of Preterm Labor

Bacterial vaginosis                                    40% increased risk

Syphilis and gonorrhea                             50% increased risk

Asymptomatic bacteriuria                         50% increased risk



Not all preterm births can or even should be prevented. Approximately 25% of all preterm births are iatrogenic; that is, babies are intentionally delivered prematurely be cause of pregnancy complications that put the life or health of the fetus or mother in danger, not because of preterm labor. Another 25% of all preterm births are preceded by spontaneous rupture of the membranes followed by labor. These preterm births are not known to be preventable. Approximately 50% of preterm births, therefore, are possibly amenable to prevention efforts and are considered idiopathic preterm births (Goldenberg & Rouse, 1998).

Sociodemographic factors such as poverty, low educational level, lack of social support, smoking, little or no prenatal care, domestic violence, and stress are thought to contribute to the 50% of preterm births that may be preventable (Curry, Perrm, & Wall, 1998; McFarlane & Gondolf, 1998; Moore & Freda, 1998). If prenatal care programs are to be effective in reducing the rate of preterm labor and birth, they must address these sociodemographic factors and develop strategies to attract all women to participate, including those at high risk for preterm labor (Maloni, 2000). Addressing the factors that contribute to preterm labor and birth can produce significant results. For example, Janke (1999) found that when women at risk for preterm birth participated in a daily program of relaxation to reduce stress and anxiety, they experienced prolonged pregnancies and gave birth to larger newborns with significantly longer gestations.


Assessment and Nursing Diagnoses

Because all pregnant women must be considered at risk for preterm labor (as they are for any other pregnancy complication), nursing assessment begins at the time of entry to prenatal care. Because the onset of preterm labor is often insidious and can be easily mistaken for normal discomforts of pregnancy, it is essential that nurses teach pregnant women how to detect the early symptoms of preterm labor (Box 24-4) (Freston et al., 1997; Peck & Griffis, 1999).

Pregnant women need to be taught what to do if the symptoms of preterm labor occur. Some women wait hours or days before contacting a health care provider after preterm labor symptoms have begun (Freston et al., 1997). Waiting too long to see a health care provider could result in inevitable preterm birth without the benefit of the administration of antenatal glucocorticoids. In this event the neonate is born at higher risk for respiratory distress syndrome and intraventricular hemorrhage. Nursing diagnoses relevant for women at risk for preterm birth include the following:

• Deficient knowledge related to

-recognition of preterm labor symptoms

• Risk for maternal or fetal injury related to

-preterm labor and birth

• Impaired mobility related to

-prescribed bed rest

• Anticipatory grieving related to

-preterm labor and birth


Expected Outcomes of Care

Expected outcomes include that the woman will do the following:

• Learn the symptoms of preterm labor and be able to assess herself and her need for intervention

• Follow teaching suggestions and call her physician or nurse-midwife if symptoms occur

• Not experience preterm symptoms, or if she does, she will take appropriate action

• Maintain her pregnancy for at least 37 completed weeks

• Give birth to a healthy, term infant


Plan of Care and Interventions


Prevention strategies that address risk factors associated with preterm labor and birth are less costly in human and financial terms than the high-tech and often lifelong care required by preterm infants and their families. Programs aimed at health promotion and disease prevention that encourage healthy lifestyles for the population in general and women of childbearing age in particular should be developed in an effort to prevent preterm labor and birth (Heaman, Sprague, & Stewart, 2001). One of the most important nursing interventions aimed at preventing preterm birth is the education of pregnant women about the early symptoms of preterm labor, so that if the symptoms occur the woman can be referred promptly to her physician or nurse-midwife for more intensive care. Box 4 identifies the symptoms of preterm labor, and the Guidelines/Guias box identifies what the woman should do if the symptoms appear. Patient education regarding any symptoms of uterine contractions or cramping between 20 and 37 weeks of gestation should be directed toward telling the woman that these symptoms are not normal discomforts of pregnancy and that contractions or cramping that do not go away should prompt the woman to contact her physician or nurse-midwife. Because no one can discriminate between Braxton-Hicks contractions and the contractions of early preterm labor, Freda and Patterson (1995) suggest that the term Braxton-Hicks contractions be eliminated from teaching about pregnancy expectations (Fig. 1).


BOX 4 Signs and Symptoms of Preterm Labor


• Uterine contractions more frequent than every

10 minutes persisting for 1 hour or more

• Uterine contractions may be painful or painless


• Lower abdominal cramping similar to gas pains; may be accompanied by diarrhea

• Dull, intermittent low back pain (below the waist)

• Painful, menstrual-like cramps

• Suprapubic pain or pressure

• Pelvic pressure or heaviness

• Urinary frequency


• Change in character and amount of usual discharge: thicker (mucoid) or thinner (watery), bloody, brown or colorless, increased amount, odor

• Rupture of amniotic membranes


Fig, 1 Nurse teaching woman signs and symptoms of preterm labor. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)


Early recognition and diagnosis

Early recognition of preterm labor is essential to successfully implement interventions such as tocolytic therapy and administration of antenatal glucocorticoids. According to the American College of Obstetricians and Gynecologists and American Academy of Pediatrics (1997), the diagnostic criteria for preterm labor are 20 to 37 weeks of gestation; documented uterine contractions; and either documented cervical change, cervical effacement of 80%, or cervical dilation of greater than 1 cm. Therefore the pregnant woman at 30 weeks with an irritable uterus but no documented cervical change is not in preterm labor. Misdiagnosis of preterm labor can lead to inappropriate use of pharmacologic agents that can be dangerous to the health of the woman or fetus.


Lifestyle modifications

Nurses caring for women who exhibit symptoms of preterm labor should question the woman about whether she has symptoms when engaged in any of the following activities:

• Sexual activity

• Riding long distances in automobiles, trains, or buses

• Carrying heavy loads such as laundry, groceries, or a small child

• Standing more than 50% of the time

• Heavy housework

• Climbing stairs

• Hard physical work

• Being unable to stop and rest when tired

If symptoms occur when the woman is engaged in any of these activities, the woman should consider what she was doing when the symptoms began, and then consider stopping those activities until 37 weeks of pregnancy when preterm birth is no longer a risk. Counseling about lifestyle modification should be individualized; only women who have symptoms of preterm labor when they are engaged in certain activities need to alter their lifestyles. There are no specific rules for which activities are safe for pregnant women and which are not. Each pregnant woman must understand which lifestyle factors might be contributing to her symptoms and be taught to modify only those factors. Sexual activity, for instance, is not prohibited during pregnancy. If, however, symptoms of preterm labor occur after sexual activity, that activity may need to be curtailed until 37 weeks of gestation.


Bed rest

Bed rest is a commonly used intervention for the prevention of preterm birth. There is no evidence in the literature to support the efficacy of this intervention, however. Maloni and colleagues (1993) have shown that there are deleterious effects of bed rest on women: after 3 days there is decreased muscle tone, weight loss, calcium loss, and glucose intolerance. Weeks of bed rest lead to bone demineralization, constipation, fatigue, isolation, anxiety, and depression (Box 5). May (1994) has also documented the father's sense of constant worry when bed rest is prescribed for his wife. Bed rest is costly for society; the estimated economic costs are based on lost wages, household and child care help expenses, and hospital costs (Goldenberg et al., 1994) (see Research box). Women on bed rest need support and encouragement whether they are at home or are hospitalized. Nurses can create support groups of hospitalized women on bed rest. Internet resources, as well as family and friends, can be important sources of support for the woman at home on bed rest (Maloni & Kuril, 2000).


BOX 5 Adverse Effects of Bed Rest


• Weight loss

• Muscle wasting, weakness

• Bone demineralization and calcium loss

• Decreased plasma volume and cardiac output

• Increased clotting tendency; risk for thrombophlebitis

• Alteration in bowel function

• Sleep disturbance, fatigue

• Prolonged postpartum recovery


• Loss of control associated with role reversals

• Dysphoria—anxiety, depression, hostility, and anger

• Guilt associated with difficulty complying with activity restriction and inability to meet role responsibilities

• Boredom, loneliness

• Emotional lability (mood swings)


• Stress associated with role reversals, increased responsibilities, and disruption of family routines

• Financial strain associated with loss of maternal income and cost of treatment

• Fear and anxiety regarding the well-being of the mother and fetus



Home care

Bed rest, although frequently prescribed, is not a benign intervention and has furthermore never been shown to decrease preterm birthrates (Maloni, 1998). Women who are at high risk for preterm birth commonly are told that it would be best if they were at home on bed rest for weeks or months. The home care of the woman at risk for preterm birth is a challenge for the nurse, who needs to assist the woman and her family in dealing with the many difficulties faced by families in which one member must be incapacitated. The scope of care given to women in their homes could range from occasional visits to monitor the maternal and fetal condition to daily telephone consultation and reading of uterine monitoring strips. Families, who are often anxious regarding the health status of the mother and baby, may need help in learning how to organize time and space or restructure family routines so that the pregnant woman can remain a part of family activity while still maintaining bed rest. It is also important for the nurse to work toward assisting all the family members to explore their feelings regarding the anxieties of preterm labor and help them to share their feelings with each other (Maloni, Brezinski-Tomasi, & Johnson, 2001) (Fig. 2 and Box 6) (see Self-Care box).

Fig. 2 Woman at home on restricted activity for preterm labor prevention. Note how she has arranged her daytime resting area so that needed items are close at hand. (Courtesy Amy Turner, Cary, NC.)


BOX 6 Activities for Children of Women on Bed Rest

• Schedule brief play periods throughout the day.

• Keep a few favorite toys in a box or basket close to the bed or couch.

• Read to the child(ren).

• Put puzzles together.

• Watch videos, play video games (remote control for TV is ideal).

• Play cards or board games.

• Color in coloring books.

• Cut out pictures from magazines and paste on cardboard.

• Play bed basketball with a soft (sponge) ball or rolled up sock and a trash can or empty laundry basket.


Patient Instructions for Self-Care

Suggested Activities for Women on Bed Rest

• Set a routine for daily activities (e.g., getting dressed, moving from the bedroom to a "day bed rest place," having social time, eating meals, self-monitoring fetal and uterine activity)

• Do passive exercises as allowed

• Review childbirth education information or have a childbirth class at home, if this can be arranged

• Plan menus and make up grocery shopping lists

• Shop by phone

• Read books about high risk pregnancy or other topics

• Keep a journal of the pregnancy

• Keep a calendar of your progress

• Reorganize files, recipes, household budget

• Update address book

• Do mending, sewing

• Listen to audiotapes, watch videos orTV

• Do crossword puzzles, jigsaw puzzles, etc.

• Do craft projects; make something for the baby

• Put pictures in photo albums

• Call a friend, family member, or support person each day or use email

• Treat yourself to a facial, manicure, neck massage, or other special treat when you need a lift


Horns uterine activity monitoring

Home care agencies provide home uterine monitoring services for women diagnosed with preterm labor (Fig. 3). However, from the body of research over the past 15 years, researchers have concluded that home uterine activity monitoring does not prevent preterm birth, and its prohibitive cost makes it an unacceptable intervention in the larger scheme of prenatal care (Dyson et al., 1998; Maloni, 2000). The use and effectiveness of home uterine activity monitoring remains controversial (Roberts & Morrison, 1998). Some research suggests that it is the nursing care offered by the home care nurse that helps women the most (lams, Johnson, & O'Shaughnessy, 1988; Moore et al., 1998).

Fig. 3 Home uterine activity monitoring. Tocodynamometer is in place at center of abdomen below umbilicus. Recording unit and transmitter are on bedside table. (Courtesy Michael S. Clement, MD, Mesa, AZ.)


Suppression of uterine activity

Tocolytics. Should preterm labor occur, women are usually admitted to the hospital for assessment; fetal monitoring; cervical/vaginal cultures; and assessment of cervical status, amniotic fluid leakage, and maternal temperature (an early sign of chorioamnionitis). The initiation of tocolytic therapy might be considered at this time. Tocolytics have been the subject of research since the late 1970s (Viamantes, 1996). At first, it was thought that use of tocolytic therapy could prolong a threatened pregnancy indefinitely; research has demonstrated that a gain of 24 hours to several days is the best outcome that can be expected (Goldenberg & Rouse, 1998; Maloni, 2000). It is now thought that the best reason to use tocolytics is that they afford the opportunity to begin administering antenatal glucocorticoids to accelerate fetal lung maturity and reduce the severity of sequelae in infants born preterm (Enkin et al., 2001; Goldenberg & Rouse, 1998).

The use of tocolysis to suppress preterm labor has increased 50%, from 1.6% in 1990 to 2.4% in 1999 (Ventura et al., 2001). The medications most commonly used for this purpose are magnesium sulfate, ritodrine, terbutaline, indomethacin, and nifedipine. Ritodrine is the only medication approved by the U.S. Food and Drug Administration (FDA) specifically for the purpose of cessation of uterine contractions. The other drugs are used for this purpose on an "unlabeled" basis (i.e., drugs known to be effective for a specific purpose though not specifically developed and tested for this purpose). There are important contraindications to the use of all tocolytics (Box 7). Because these medications have the potential for serious adverse reactions for mother and fetus, close nursing supervision during treatment is critical (Lehne, 2001) (Box 8 and Table 1).


BOX 7 Contraindications to Tocolysis


Severe pregnancy-induced hypertension or eclampsia

Active vaginal bleeding

Intrauterine infection

Cardiac disease

Medical or obstetric condition that contraindicates continuation

of pregnancy


Estimated gestational age over 37 weeks

Dilation over 4 cm

Fetal demise

Lethal fetal anomaly


Acute fetal distress

Chronic ILJGR


BOX 8 Nursing Care for Women Receiving Tocolytic Therapy

Explain the purpose and side effects of tocolytic therapy to woman and her family.

Position woman on her side to enhance placental perfusion and reduce pressure on the cervix.

Monitor maternal vital signs, FHR, and labor status according to hospital protocol and professional standards.

Assess mother and fetus for signs of adverse reactions related to the tocolytic being administered.

Determine maternal fluid balance by measuring daily weight and intake and output (I&O).

Limit fluid intake to 2500 to 3000 ml/day, especially if a beta-adrenergic agonist is being administered.

Provide psychosocial support and opportunities for women and family to express feelings and concerns.

Offer comfort measures as required.

Encourage diversional activities and relaxation techniques.


Table 1 Medication Guide: Tocolitic Therapy for preterm Labor





Ritodrine (Yutopar) Beta-adrenergic agonist

Relaxes smooth muscles, inhibiting uterine activity and causing bronchodilation

Mix 150 mg in 500 ml isotonic intravenous solution

Attach to controller pump and piggyback to primaryinfusion

Begin infusion at 0.05 to 0.1 mg/min Increase rate by 0.05 mg q10min until contractions stop, intolerable adverse reactions develop, or a maximum dose of 0.35 mg/min is reached

Maintain effective dose for 12 to 24 hr

Intravenous adverse reactions:

• Shortness of breath, coughing, tachypnea, pulmonary edema

• Tachycardia, palpitations, skipped beats

• Chest pains

• Hypotension

• Tremors, dizziness, nervousness

• Muscle cramps and weakness

• Headache

• Hyperglycemia; hypokalemia

• Nausea and vomiting

• Fetal tachycardia Oral adverse reactions:

• Significant adverse effects are rare

• Gl distress

Women should be screened with ECG before therapy begins; maternal heart disease and hypertension are contraindications

Use cautiously if woman has type 1 diabetes or hyperthyroidism

Validate that woman is in PTL and is over 20 weeks of gestation

Assess woman and fetus before and after each rate increase and following frequency of agency protocol

Discontinue infusion and notify physician if

• Maternal heart rate greater than 120 to 140 beats/min; dysrhythmias, chest pain

• BP is less than 90/60 mm Hg

• Fetal heart rate greater than 180 beats/min

Ensure that propranolol (Inderal) is available to reverse adverse effects related to cardiovascular function

Terbutaline* (Brethine)

Beta-adrenergic agonist

Relaxes smooth muscles, inhibiting uterine activity and causingbronchodilation

Subcutaneous injection:

• 0.25 mg q30min for 2 hr

• Maximum dose: 0.5 mg q4-6h

Subcutaneous pump:

• Maintenance dose 0.05-0.1 mg/hr

• Bolus: 0.25 mg q4-6h according to contraction pattern

• 3 mg/24 hr

Similar to ritodrine

Teach woman and family:

• Assessment measures: pulse, BP, respiratory effort, insertion site for infection, signs of PTL and adverse reactions of terbutaline

• Who to call if problems or concerns arise

• Site care and pump


• Activity restrictions Arrange for follow-up

Magnesium* sulfate

CNS depressant; relaxes smooth muscles including uterus

Mix 40 g in 1000 ml intravenous solution, piggyback to primary infusion, and administer loading dose or bolus of 4-6 g using controller pump over 15 to 20 min

Continue maintenance infusion at 1 g/hr, increasing to a maximum 3 g/hr until contractions stop or intolerable adverse reactions develop

During loading dose:

• Hot flushes, sweating, nausea and vomiting, drowsiness, and blurred vision; usually subside when loading dose is completed

Intolerable adverse reactions:

• Respiratory rate less than 12 breaths/min

• Absent DTRs

• Severe hypotension

• Extreme muscle weakness

• Urine output less than 25-30 ml/hr

• Serum magnesium level of 10 mEq/L or greater

Assess woman and fetus before and after each rate increase and following frequency of agency protocol Monitor serum magnesium levels; therapeutic level should range between 4 and 7.5 mEq/L

Discontinue infusion and notify physician if intolerable adverse reactions occur

Ensure that calcium gluconate is available for emergency administration to reverse magnesium sulfate toxicity

Limit IV fluid intake to 125 ml/hr

Nifedipine* (Procardia;


Calcium channel blocker; relaxes smooth muscles including the uterus by blocking calcium entry

nitial dose: 10-20 mg

Maintenance dose: 10 to 20 mg q4-6h PO

Transient tachycardia, palpitations


Dizziness, headache.


Peripheral edema



Facial flushing

Do not use with magnesium


Assess woman and fetus according to agency protocol being alert for adverse reactions

Do not use sublingual route


Prostaglandin inhibitor; relaxes uterine smooth muscle

Initial dose: 50 mg (orally or rectally)

Maintenance dose: 25-50 mg, q4-6h for 24-48 hr (PO)

Facial flushing

Maternal: nausea and vomiting, dyspepsia, dizziness, oligohyramnios

Fetal: premature closure of ductus arteriosus

Neonate: bronchopulmonary dysplasia, respiratory distress syndrome, intracranial hemorrhage, necrotizing enterocolitis, hyperbilirubinemia

Used when other methods fail; never used after 35 weeks of gestation

Do not use for women with bleeding potential

Fetal assessment: amniotic fluid level; function of ductus arteriosus


Magnesium sulfate is the most commonly used tocolytic agent, although its exact mechanism of action on uterine muscle is unclear. Because it acts as a central nervous system depressant, it has been used for decades for seizure control in women with preeclampsia; it began to be used for tocolysis in the 1970s (lams, 2002). At the onset of preterm labor, magnesium sulfate is administered via an intravenous infusion. Terbutaline, 0.25 mg, may be injected subcutaneously before the initiation of the magnesium sulfate infusion and then administered again by subcutaneous pump as the infusion is discontinued (see Table 1).

Ritodrine and terbutaline, beta-adrenergic agonist medications for tocolysis, work by relaxing smooth muscle. When used, ritodrine is usually administered intravenously as one of the first steps in suppressing preterm labor. Terbutaline is most commonly administered by a subcutaneous injection of 0.25 mg to suppress uterine hyperactivity or by a subcutaneous pump. Effectiveness of pump therapy in prolonging gestation is controversial (Guinn et al., 1998). Beta-adrenergic agonists have many maternal and fetal side effects and must always be used with extreme caution and careful, conscientious nursing care. Medication administration and nursing care are aimed at maintaining a therapeutic level of medication and avoiding the most serious side effects while maintaining optimal health of the fetus (see Table 1).


NURSE ALERT! Caution must be used when administering intravenous fluids to women in preterm labor because this practice can increase the risk for tocolyticinduced pulmonary edema, especially when a betaadrenergic agonist is used. It is recommended that the total oral and intravenous fluid intake in 24 hours should be restricted to 2400 to 3000 ml. Strict intake and output measurement, daily weight determination, and assessment of pulmonary function should be instituted (American College of Obstetricians and Gynecologists [ACOG], 1995a; Freda & DeVore, 1996; Hill, 1995).


Indomethacin, a nonsteroidal antiinflammatory medication, has been shown in some trials to cause a cessation of uterine contractions by blocking the action of prostaglandins (Besinger et al, 1991; Lehne, 2001). The severity of fetal side effects associated with the use of indomethacin for tocolysis makes it less common than other classes of tocolytic drugs. However, Macones and Robinson (1998) studied the risk of using indomethacin versus the benefit of delayed birth in 1000 women and found that it was more beneficial to the fetus for the mother to have received indomethacin and the fetus to have gained gestational age than was preterm birth at 32 weeks (see Table 1).

Nifedipine, a calcium channel blocker, is another tocolytic agent that can suppress contractions (Lehne, 2001; Read & Wellby, 1986). It works by inhibiting calcium from entering smooth muscle cells, thus reducing uterine contractions. Despite mild maternal side effects, this medication might be used less than other tocolytic agents because of concerns about fetal side effects. When the tocolytic effects and maternal tolerance of nifedipine and ritodrine were compared, no significant differences in length of delay of birth were found, but significantly fewer maternal side effects occurred with nifedipine (Garcia-Velasco & Gonzalez-Gonzalez, 1998) (see Table 1).


Promotion of fetal lung maturity

Antenatal glucocorticoids. Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. It is viewed as a form of care

likely to be beneficial (Enkin et al., 2001). This class of medications also seems to decrease rates of intraventricular hemorrhage in preterm infants (Goldenberg & Rouse, 1998). All women between 24 and 34 weeks of gestation should be given antenatal glucocorticoids when preterm birth is threatened, unless there is a medical indication for immediate delivery such as cord prolapse, chorioamnionitis, or abruptio placentae. The regimen for administration of antenatal glucocorticoids is given in the Medication Guide.


Medication Guide Antenatal Glucocorticoid Therapy with Betamethasone, Dexamethasone


Stimulates fetal lung maturation by promoting release of enzymes that induce production or release of lung surfactant. NOTE: The FDA has not approved these medications for this use (i.e., this is an unlabeled use for obstetrics).


To prevent or reduce the severity of respiratory distress syndrome in preterm infants between 24 and 34 weeks of gestation


Betamethasone: 12 mg IM x 2 doses 12 hr apart

Dexamethasone: 6 mg IM x 2 doses 12 hr apart

May be repeated in 7 days if birth has not occurred.


Possible maternal infection, pulmonary edema (if given with /3-adrenergic medications), may worsen maternal condition (diabetes, hypertension)


Give deep IM in gluteal muscle. Teach signs of pulmonary edema. Assess blood glucose levels and lung sounds. Do not give if woman has infection. Use in women with PPROM not universally recommended.


Management of inevitable preterm birth

Labor that has progressed to a cervical dilation of 4 cm is likely to lead to inevitable preterm birth. Preterm births in tertiary care centers lead to better neonatal and maternal outcomes. Women considered at risk for inevitable preterm birth should be transferred quickly to such a facility to ensure the best possible outcome. The first dose of antenatal glucocorticoids should be given before transfer because these medications require 24 hours to take effect.

Although maternal transport helps ensure a better health outcome for the mother and the baby, it may have complications. Women may be transported to tertiary care centers far from home, making visits by the family difficult and increasing the anxiety levels of the woman and her family.



Evaluation of the nursing care provided for a woman at risk for preterm birth is based on the expected outcomes of care (see Plan of Care).


PLAN OF CARE Preterm Labor

NURSING DIAGNOSIS Deficient knowledge related to recognition of preterm labor

Expected Outcome Woman and significant other delineate the signs and symptoms of preterm labor.

Nursing Interventions/Rationales

Assess what the partners know about abnormal signs and symptoms during pregnancy to identify areas of deficit.

Discuss signs and symptoms that serve as warning signs of preterm labor so that the woman or her partner has adequate information to identify problems early.

Provide written supplemental materials that include a list of warning signs and instructions regarding what to do if any of the listed signs occur so that the couple can reinforce and review learning and act swiftly and appropriately should a sign occur.

Discuss and demonstrate how to assess and time the contractions to provide needed skills to assess the signs of labor.


NURSING DIAGNOSIS Risk for maternal/fetal injury related to recurrence of preterm labor

Expected outcomes Woman demonstrates ability to assess self and fetus for signs of recurring labor; maternal-fetal well-being is maintained.

Nursing Interventions/Rationales

Teach woman/partner how to monitor fetal and uterine contraction activity daily to provide immediate evidence of a worsening condition.

Have woman/partner report rupture of membranes, vaginal bleeding, cramping, pelvic pressure, or low backache to appropriate health care resource immediately because such symptoms are signs of labor.

If home uterine activity monitoring is to be used, teach woman/partner how to use the monitoring device and how to transmit the data to the health care provider via telephone to enhance correct use of monitoring device and increase the accuracy of detection of early labor.

Have woman monitor her weight, diet, fluid intake, and vital signs on a daily basis to evaluate for potential problems.

Limit activities to bed rest with bathroom privileges to decrease the likelihood of onset of labor.

Use a side-lying position to enhance placental perfusion.

Abstain from sexual intercourse and nipple stimulation because such activities may stimulate uterine contractions.

Practice relaxation techniques to decrease uterine tone and decrease anxiety and stress.

Take tocolytic or other medications per physician's orders to inhibit uterine contractions.

Teach woman/partner about and have them report any medication side effects immediately to prevent medicationinduced complications.

Have family arrange for alternative strategies in carrying out the woman's usual roles and functions to decrease stress and limit temptations to increase activity.

If small children are part of the household, encourage family to make alternative arrangements for child care to enhance woman's adherence to bed rest protocol.


NURSING DIAGNOSIS Anxiety related to preterm labor and potentially premature neonate

Expected outcome Feelings and symptoms of fear/anxiety abate.

Nursing Interventions/Rationales

Provide a calm, soothing atmosphere and teach family to provide emotional support to facilitate coping.

Encourage verbalization of fears to decrease intensity of emotional response.

Involve woman and family in the home management of her condition to promote a greater sense of control.

Help the woman identify and use appropriate coping strategies and support systems to reduce fear/anxiety.

Explore the use of desensitization strategies such as progressive muscle relaxation, visual imagery, or thought stopping to reduce fear-related emotions and related physical symptoms.


NURSING DIAGNOSIS Deficient diversions! Activity related to imposed bed rest

Expected outcome Verbalization of diminished feelings of boredom.

Nursing Interventions/Rationales

Assist woman to creatively explore personally meaningful activities that can be pursued from the bed to ensure activities that have meaning, purpose, and value to the individual.

Maintain emphasis on personal choices of the woman because doing so promotes control and minimizes imposition of routines by others.

Evaluate what support and system resources are available in the environment to assist in providing diversional activities.

Explore ways for the woman to remain an active participant in home management and decision making to promote control.

Engage support of family and friends in carrying out chosen activities and making necessary environmental alterations to ensure success.

Teach woman about stress management and relaxation techniques to help manage tension of confinement.


Premature rupture of membranes (PROM) is the rupture of the amniotic sac and leakage of amniotic fluid beginning at least 1 hour before the onset of labor at any gestational age. Preterm premature rupture of membranes (PPROM) (i.e., membranes rupture before 37 weeks of gestation) occurs in up to 25% of all cases of preterm labor. Infection often precedes PPROM, but the etiology of PPROM remains unknown. PPROM is diagnosed after the woman complains of either a sudden gush of fluid from the vagina or a slow leak of fluid from the vagina.

Infection is the serious side effect of PPROM that makes it a major complication of pregnancy. Chorioamnionitis is an intraamniotic infection of the chorion and amnion that is potentially life threatening for the fetus and the woman. Most cases of intrauterine infection respond well to antibiotics, yet sepsis can occur and can lead to maternal death. Fetal complications from chorioamnionitis include congenital pneumonia, sepsis, and meningitis (Mercer & Lewis, 1997). Even in the absence of infection, PPROM can precipitate cord prolapse or cause oligohydramnios leading to cord compression, potentially lifethreatening complications for the fetus.



When PPROM is suspected, strict sterile technique should be used in any vaginal examination to avoid introduction of infection. A Nitrazine or fern test is used to determine whether the discharge is amniotic fluid (see Chapter 14, Procedure Box: Tests for Rupture of Membranes, p. 326). A woman with this diagnosis is often cared for at home, with more frequent visits to her physician or nurse-midwife. Expectant management will continue as long as there are no signs of infection or fetal distress. Nursing support of the woman and her family is critical at this time. She is often anxious about the health of her baby and may fear that she was responsible in some way for the membrane rupture. The nurse needs to encourage expression of feelings and concerns, provide information, and make referrals as needed (Weitz, 2001).

Frequent biophysical profiles are performed to determine fetal health status and estimate amniotic fluid volume. The woman with PPROM should also be taught how to count fetal movements daily because a slowing of fetal movement has been shown to be a precursor to severe fetal compromise. Several methods are commonly used to count fetal movements; one method for fetal movement counting is described in the Self-Care box (Freda et al., 1993). Antenatal glucocorticoids may be administered if chorioamnionitis is absent (ACOG, 1998; Weitz, 2001).

Vigilance for signs of infection is a major part of the nursing care and patient education following PPROM. The woman needs to be taught how to keep her genital area clean and that nothing should be introduced into her vagina. Signs of infection (e.g., fever, foul-smelling vaginal discharge, rapid pulse) should be reported to the physician or nurse-midwife immediately. Prophylactic antibiotic therapy may be ordered because it improves perinatal outcome (ACOG, 1998).


A postterm pregnancy, or prolonged pregnancy, is one that extends beyond the end of week 42 of gestation, or 294 days from the first day of the last menstrual period. The incidence of postterm pregnancy is estimated to be between 4% and 14%, with an average of 10% (Cunningham et al, 2001).

Many pregnancies are misdiagnosed as prolonged. This can occur because (1) the pregnancy is inaccurately dated because the woman has an irregular menstrual cycle pattern, (2) an accurate date of the last menstrual period is unknown, or (3) entry into prenatal care was delayed or did not occur. Interestingly, a woman who experiences one postterm pregnancy is 30% to 40% more likely to experience it again in subsequent pregnancies (Arulkumarian, 1997).

Clinical manifestations of postterm pregnancy include maternal weight loss, decreased uterine size, meconium in the amniotic fluid, and advanced bone maturation of the fetal skeleton with an exceptionally hard fetal skull (Gilbert & Harmon, 1998).



Maternal risks are often related to the birth of an excessively large infant. The woman is at increased risk for dysfunctional labor; birth canal trauma, including lacerations and extension of episiotomy related to vaginal birth; postpartum hemorrhage; and infection. Interventions such as induction of labor with oxytocin, forcepsor vacuum-assisted birth, and cesarean birth are more likely to be necessary. The woman also may experience fatigue and psychologic reactions such as depression, frustration, and feelings of inadequacy as she passes her estimated date of birth (Arulkumarian, 1997; Freeman & Lagrew, 1996; Gilbert & Harmon, 1998).

Fetal risks appear to be twofold. The first is the possibility of prolonged labor, shoulder dystocia, birth trauma, and asphyxia from macrosomia. Macrosomia occurs when the placenta continues to provide adequate nutrients to support fetal growth after 40 weeks of gestation. It is estimated to occur in approximately 25% of prolonged pregnancies (Divon, 2002). The second risk is the compromising effects on the fetus of an "aging" placenta. Spellacy (1999) notes that placental function gradually decreases after 37 weeks of gestation. Amniotic fluid volume (AFV) declines to approximately 800 ml by 40 weeks of gestation and to approximately 400 ml by 42 weeks of gestation. The resulting oligohydramnios can lead to fetal hypoxia related to cord compression. If placental insufficiency is present, there is a high likelihood of fetal distress occurring during labor. Neonatal problems may include asphyxia, meconium aspiration syndrome, dysmaturity syndrome, hypoglycemia, polycythemia, and respiratory distress (Gilbert & Harmon, 1998).



The management of postterm pregnancy is still controversial. The induction of labor at 41 to 42 weeks is suggested by some authorities as a means of reducing the rate of cesarean birth and stillbirth or neonatal death (Hannah et al., 1996). Others follow a more individualized approach, allowing the pregnancy to proceed to 43 weeks of gestation as long as assessment of fetal well-being using a combination of tests is performed and the results of the tests are normal (Searing, 2001).


LEGAL TIP Informed Consent Regarding Care During Postterm Pregnancy

The woman with a postterm pregnancy should be informed about the risks and benefits of both treatment and nontreatment. The standard of practice for postterm pregnancy is to begin antepartal surveillance (e.g., maternal assessments and tests of fetal well-being) by 14 days after the EDB, no matter how the date was derived. The woman and her physician or nursemidwife should mutually agree on a plan of care (Wood, 1994).


Antepartum assessments for postterm pregnancy may include daily fetal movement counts, nonstress tests, amniotic fluid volume assessments, contraction stress tests, biophysical profiles, and Doppler flow measurements. The woman and her family should be fully informed regarding the tests performed and the meaning of the results obtained.

The amniotic fluid index should be greater than 8 with at least one pocket of amniotic fluid greater than 2 cm, and amniotic fluid should be present throughout the uterine cavity (Gilbert & Harmon, 1998; Schmidt, 1999). The biophysical profile may be the best way of gauging fetal well-being because it combines nonstress testing with realtime ultrasound scanning to assess fetal movements, fetal breathing movements, and the AFV. Determining the AFV is critical in women with postterm pregnancies because a decreased AFV (i.e., oligohydramnios) has been associated with fetal stress as a result of umbilical cord compression.

Cervical checks usually are performed weekly after 40 weeks of gestation to determine whether the condition of the cervix is favorable for induction (9 or greater on the Bishop score) (see Table 4). Vaginal secretions may be assessed for the amount of fetal fibronectin; however results of studies have been inconclusive (Divon, 2002). Amniocentesis or amnioscopy may be performed to detect meconium in the amniotic fluid (Spellacy, 1999).

During the postdate period the woman is encouraged to assess fetal activity daily, assess for signs of labor, and keep appointments with her physician or nurse-midwife (see Self-Care box). The woman and her family should be encouraged to express their feelings about the prolonged pregnancy. Referral to a support group or another supportive resource may be needed (Schmidt, 1999).


Patient Instructions for Self-Care Postterm Pregnancy

Perform daily fetal movement counts.

Assess for signs of labor.

Call your primary health care provider if your membranes rupture, or if you perceive a decrease in or no fetal movement.

Keep appointments for fetal assessment tests or cervical checks.

Come to the hospital soon after labor begins.


If the woman's cervix is ripe, labor is usually induced with oxytocin. If her cervix is not ripe, continued fetal surveillance or a cervical ripening agent (e.g., prostaglandin insert or gel) may be administered followed by oxytocin induction (Gilbert & Harmon, 1998; Schmidt, 1999).

The fetus of a woman with a postterm pregnancy should be monitored electronically for a more accurate assessment of the FHR pattern. If oligohydramnios is pre sent, amnioinfusion may be implemented to restore amniotic fluid volume and thereby maintain a cushioning of the cord. Inadequate fluid volume leads to compression of the cord, which results in fetal hypoxia that is reflected in variable or prolonged deceleration patterns and passage of meconium. Amnioinfusion may also be used to prevent or minimize meconium aspiration syndrome by diluting amniotic fluid thickened with meconium passed by a hypoxic fetus. Maternal-fetal risks related to amnioinfusion, although rare, can result from infection and overdistention of the uterine cavity with infused fluid (Folsom, 1997; Gilbert & Harmon, 1998; Schmidt, 1997). Accurate assessment of the woman's labor pattern also is important because dysfunctional labor is common (Spellacy, 1999).

Emotional support is essential for the woman with a postterm pregnancy and her family. A vaginal birth is anticipated, but the couple should be prepared for a forcepsassisted, vacuum-assisted, or cesarean birth if complications arise.

LABOR AND BIRTH AT RISK (Obstetric operations, Obstetric emergencies). Nursing Care during Labour and delivery with risk Factors.



• Differentiate between preterm birth and low birth weight.

• Identify the risk factors for preterm labor.

• Discuss current interventions to prevent preterm birth.

• Discuss the use of tocolytics and antenatal glucocorticoids in preterm labor and birth.

• Examine the effects of prescribed bed rest on pregnant women and their families.

• Describe nursing management of a trial of labor, induction and augmentation of labor, forceps- and vacuum-assisted birth, cesarean birth, and vaginal birth after cesarian.

Discuss the criteria for evaluating the nursing care of women experiencing labor and birth complications.

Describe the care of a woman experiencing postterm pregnancy.

Discuss obstetric emergencies and their appropriate management.



amniotic fluid embolism (AFE) Embolism resulting from amniotic fluid entering the maternal bloodstream during labor and birth after rupture of membranes; often fatal to the woman if it is a pulmonary embolism

antenatal glucocorticoids Medications administered to the mother for the purpose of accelerating fetal lung maturity when there is increased risk for preterm birth between 24 and 34 weeks of gestation

augmentation of labor Stimulation of ineffective uterine contractions after labor has started spontaneously but is not progressing satisfactorily

Bishop score Rating system to evaluate inducibility (ripeness) of the cervix; a higher score increases the likelihood of a successful induction of labor

cephalopelvic disproportion (CPD) Condition in which the infant's head is of such a shape, size, or position that it cannot pass through the mother's pelvis or the maternal pelvis is too small, abnormally shaped, or deformed to allow the passage of a fetus of average size

cesarean birth Birth of a fetus by an incision through the abdominal wall and uterus

chorioamnionitis Inflammatory reaction in fetal membranes to bacteria or viruses in the amniotic fluid, which then become infiltrated with polymorphonuclear leukocytes

dysfunctional labor Abnormal uterine contractions that prevent normal progress of cervical dilation, effacement, or descent

dystocia Prolonged, painful, or otherwise difficult birth caused by various conditions associated with the five factors affecting labor (powers, passage, passenger, maternal position, and maternal emotions)

external cephalic version (ECV) Turning of the fetus to a vertex presentation by external exertion of pressure on the fetus through the maternal


forceps-assisted birth Vaginal birth in which forceps (i.e., curved-bladed instruments) are used to assist in the birth of the fetal head

hypertonic uterine dysfunction Uncoordinated, painful, frequent uterine contractions that do not cause cervical dilation and effacement; primary dysfunctional labor

hypotonic uterine dysfunction Weak, ineffective uterine contractions usually occurring in the active phase of labor; often related to cephalopelvic disproportion or malposition of the fetus; secondary uterine inertia

oxytocin Hormone produced by the posterior pituitary gland that stimulates uterine contractions and the release of milk in the mammary glands (let-down reflex); oxytocics are medications that mimic the uterine stimulating action of oxytocin

postterm pregnancy Pregnancy prolonged past 42 weeks of gestation

precipitous labor Rapid or sudden labor lasting less than 3 hours from the onset of uterine contractions to complete birth of the fetus

premature rupture of membranes (PROM) Rupture of the amniotic sac and leakage of amniotic fluid beginning at least 1 hour before the onset of labor at any gestational age

preterm birth Birth occurring before the completion of 37 weeks of gestation

preterm labor Cervical changes and uterine contractions occurring between 20 weeks and 37 weeks of pregnancy

preterm premature rupture of membranes (PPROM) PROM that occurs before 37 weeks of gestation

prolapse of the umbilical cord Protrusion of the umbilical cord in advance of the presenting part

shoulder dystocia Condition in which the head is born but the anterior shoulder cannot pass under the pubic arch

therapeutic rest Administration of analgesics and implementation of comfort/relaxation measures to decrease pain and induce rest for management of hypertonic uterine dysfunction

tocolytics Medications used to suppress uterine activity and relax the uterus in cases of hyperstimulation or preterm labor

trial of labor (TOL) Period of observation to determine whether a laboring woman is likely to be successful in progressing to a vaginal birth

vacuum-assisted birth Birth involving attachment of a vacuum cap to the fetal head (occiput) and applying negative pressure to assist in birth of the fetus

vaginal birth after cesarean (VBAC) Giving birth vaginally after having had a previous cesarean birth



When complications arise during labor and birth, risk of perinatal morbidity and mortality increases. Some complications are anticipated, especially if the mother is identified as high risk during the antepartum period; others are  unexpected or unforeseen. The woman, her family, and the obstetric team can feel devastated when things go wrong. Nurses must recognize these feelings if they are to provide effective support. It is crucial for nurses to understand the normal birth process to prevent and detect deviations from normal labor and birth and to implement nursing measures when complications arise. Optimal care of the laboring woman, fetus, and family experiencing complications is possible only when the nurse and other members of the obstetric team use their knowledge and skills in a concerted effort to provide care. This chapter focuses on the problems of preterm labor and birth, dystocia, and postterm pregnancy and obstetric emergencies.



Dystocia is long, difficult, or abnormal labor; it is caused by various conditions associated with the five factors affecting labor. It is estimated that dystocia occurs in approximately 8% to 11% of women during the first stage of labor when the fetus is in a vertex presentation. Secondstage dystocia is equally as common (Wiznitzer, 1995).

Dystocia can be caused by any of the following:

• Dysfunctional labor, resulting in ineffective uterine contractions or maternal bearing-down efforts (the powers); the most common cause of dystocia (Cunningham et al., 2001)

• Alterations in the pelvic structure (the passage)

• Fetal causes, including abnormal presentation or position, anomalies, excessive size, and number of fetuses (the passenger)

• Maternal position during labor and birth

• Psychologic responses of the mother to labor related to past experiences, preparation, culture and heritage, and support system

These factors are interdependent. In assessing the woman for an abnormal labor pattern, the nurse must consider the way in which these factors interact and influence labor progress. Dystocia is suspected when there is an alteration in the characteristics of uterine contractions, a lack of progress in the rate of cervical dilation, or a lack of progress in fetal descent and expulsion.



Dysfunctional labor is described as abnormal uterine contractions that prevent the normal progress of cervical dilation, effacement (primary powers), or descent (secondary powers). Dysfunction of uterine contractions can be further described as being hypertonic or hypotonic.

Several factors seem to increase a woman's risk for uterine dystocia, including the following:

• Body build (e.g., 30 pounds or more overweight, short stature)

• Uterine abnormalities (e.g., congenital malformations, overdistention as with multiple gestation or hydramnios)

• Malpresentations and positions of the fetus

• Cephalopelvic disproportion

• Overstimulation with oxytocin

• Maternal fatigue, dehydration and electrolyte imbalance, and fear

• Inappropriate timing of analgesic or anesthetic administration

Research has also documented a familial occurrence of dystocia. Laboring women whose mothers or sisters experienced dystocia during their labors had an increased risk for experiencing dystocia themselves, possibly related to a genetic factor affecting uterine activity (Berg-Lekas, Hogberg, & Winkvist, 1998).


Hypertonic uterine dysfunction

The woman experiencing hypertonic uterine dysfunction, or primary dysfunctional labor, often is an anxious first-time mother who is having painful and frequent contractions that are ineffective in causing cervical dilation or effacement to progress. These contractions usually occur in the latent stage (cervical dilation of less than 4 cm) and are usually uncoordinated (Fig. 4). The force of the contractions may be in the midsection of the uterus rather than in the fundus, and the uterus is therefore unable to apply downward pressure to push the presenting part against the cervix. The uterus may not relax completely between contractions (Gilbert & Harmon, 1998; Varney, 1997).


Fig. 4 Uterine contractility patterns in labor. A, Typical normal labor. B, Subnormal intensity, with frequency greater than needed for optimum performance. C, Normal contractions but too infrequent for efficient labor. D, Incoordinate activity. E, Hypercontractility.


Women experiencing hypertonic uterine dysfunction may be exhausted and express concern about loss of control because of the intense pain they are experiencing and the lack of progress. Therapeutic rest, which is achieved with a warm bath or shower and the administration of analgesics such as morphine, meperidine (Demerol), or nalbuphine (Nubain) to inhibit uterine contractions, reduce pain, and encourage sleep, is usually prescribed for the management of hypertonic uterine dysfunction. After a 4- to 6-hour rest these women are likely to awaken in active labor with a normal uterine contraction pattern (Gilbert & Harmon, 1998).


Hypotonic uterine dysfunction

The second and more common type of uterine dysfunction is hypotonic uterine dysfunction, or secondary uterine inertia. The woman, who may be in her first or a subsequent pregnancy, initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop altogether (see Fig. 4). The uterus is easily indented, even at the peak of contractions. Intrauterine pressure during the contraction (usually less than 25 mm Hg) is insufficient for progress of cervical effacement and dilation (Gilbert & Harmon, 1998). Cephalopelvic disproportion and malpositions are common causes of this type of uterine dysfunction.

A woman experiencing hypotonic uterine dysfunction may become exhausted and be at increased risk for infection. Management usually consists of performing an ultrasound examination to rule out cephalopelvic disproportion and assessing the fetal heart rate and pattern, characteristics of amniotic fluid if membranes are ruptured, and  maternal well-being. If findings are normal, measures such as ambulation, hydrotherapy, an enema, stripping or rupture of membranes, nipple stimulation, and oxytocin infusion can be used to augment the progress of labor (Varney, 1997).


Secondary powers

Secondary powers, or bearing-down efforts, are compromised when large amounts of analgesic are given. Anesthesia may also block the bearing-down reflex and, as a result, alter the effectiveness of voluntary efforts (Mayberry et al., 1999). Exhaustion resulting from lack of sleep or long labor and fatigue resulting from inadequate hydration and food intake affect the woman's voluntary efforts. Maternal position can work against the forces of gravity and decrease the strength and efficiency of the contractions. Table 2 summarizes the characteristics of dysfunctional labor.


Table 2. Dysfunctional Labor: Primary and Secondary Powers





Usually occurs before 4 cm dilation; cause unknown, may be related to fear and tension (primary powers)

Cause may be pelvic contracture and fetal malposition, overdistention of uterus (e.g., twins), or unknown (primary powers)

Involves abdominal and levator ani muscles

Occurs in second stage of labor; cause may be related to nerve block anesthetic, analgesia, exhaustion


Pain out of proportion to intensity of contraction

Pain out of proportion to effectiveness of contraction in effacing and dilating the cervix

Contractions increase in frequency

Contractions uncoordinated

Uterus is contracted between contractions, cannot be indented

Contractions decrease in frequency and intensity

Uterus easily indentable even at peak of contraction

Uterus relaxed between contractions (normal)

No voluntary urge to push or bear down or inadequate/ineffective pushing


Loss of control related to intensity of pain and lack of progress




Psychologic trauma

Spontaneous vaginal birth prevented


Fetal asphyxia with meconium aspiration

Fetal infection

Fetal and neonatal death

Fetal asphyxia


Initiate therapeutic rest measures

• Administer analgesic (e.g., morphine, nalbuphine, meperidine) if membranes not ruptured or cephalopelvic disproportion not present

• Relieve pain to permit mother to rest

• Assist with measures to enhance rest and relaxation (e.g., hydrotherapy)

Rule out cephalopelvic disproportion

Stimulate labor with oxytocin (augmentation)

Perform amniotomy

Assist with measures to enhance the progress of labor (e.g., position changes, ambulation, hydrotherapy)

Coach mother in bearing down with contractions; assist with relaxation between contractions

Position mother in favorable position for pushing

Reduce epidural infusion rate

Apply low forceps or vacuum if assistance is needed

Schedule cesarean birth only if nonreassuring fetal status occurs


Alterations in pelvic structure

Pelvic dystocia. Pelvic dystocia can occur whenever there are contractures of the pelvic diameters that reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.

Disproportion of the pelvis is the least common cause of dystocia (Cunningham et al., 2001). Pelvic contractures may be caused by congenital abnormalities, maternal malnutrition, neoplasms, or lower spinal disorders. An immature pelvic size predisposes some adolescent mothers to pelvic dystocia. Pelvic deformities may also be the result of automobile or other accidents.

An inlet contracture is diagnosed whenever the diagonal conjugate is less than 11.5 cm. The incidence of face and shoulder presentation is increased. Because these presentations interfere with engagement and fetal descent, the risk of prolapse of the umbilical cord is increased. Inlet contracture is associated with maternal rickets and a flat pelvis. Weak uterine contractions may be noted during the first stage of labor in affected women.

Midplane contracture, the most common cause of pelvic dystocia, is diagnosed whenever the sum of the interischial spinous and posterior sagittal diameters of the midpelvis is 13.5 cm or less. Fetal descent is arrested (transverse arrest of the fetal head) in such births because the head cannot rotate internally. These infants are usually born by cesarean, but vacuum-assisted birth has been used safely when the cervix is fully dilated. Midforceps-assisted birth usually is not done because of the increased perinatal morbidity associated with this intervention.

Outlet contracture exists when the interischial diameter is 8 cm or less. It rarely occurs in the absence of midplane contracture. Women with outlet contracture have a long, narrow pubic arch and an android pelvis, and this causes fetal descent to be arrested. Maternal complications include extensive perineal lacerations during vaginal birth because the fetal head is pushed posteriorly.

Soft tissue dystocia. Soft tissue dystocia results from obstruction of the birth passage by an anatomic abnormality other than that involving the bony pelvis. The obstruction may result from placenta previa (low-lying placenta) that partially or completely obstructs the internal os of the cervix. Other causes, such as leiomyomas (uterine fibroids) in the lower uterine segment, ovarian tumors, and a full bladder or rectum, may prevent the fetus from entering the pelvis. Occasionally, cervical edema occurs during labor when the cervix is caught between the presenting part and the symphysis pubis or when the woman begins bearing-down efforts prematurely, thereby inhibiting complete dilation. Sexually transmitted infections (e.g., human papillomavirus) can alter cervical tissue integrity and thus interfere with adequate effacement and dilation. Bandl's ring, a pathologic retraction ring, is associated with prolonged rupture of membranes and protracted labor (Cunningham et al., 2001).


Fetal causes

Dystocia of fetal origin may be caused by anomalies, excessive fetal size and malpresentation, malposition, or multifetal pregnancy. Complications associated with dystocia of fetal origin include neonatal asphyxia, fetal injuries or fractures, and maternal vaginal lacerations. Although spontaneous vaginal birth is possible in these instances, a low-forceps-assisted, vacuum-assisted, or cesarean birth often is necessary.

Anomalies. Gross ascites, large tumors, and open neural tube defects (e.g., myelomeningocele, hydrocephalus) are fetal anomalies that can cause dystocia. The anomalies affect the relationship of the fetal anatomy to the maternal pelvic capacity, with the result that the fetus is unable to descend through the birth canal.

Cephalopelvic disproportion. Cephalopelvic disproportion (CPD), also called fetopelvic disproportion, is related to excessive fetal size (i.e., 4000 g or more). It occurred at a rate of 18.3 per 1000 live births in 1999 (Ventura et al., 2001).

When CPD is present, the fetus cannot fit through the maternal pelvis to be born vaginally. Excessive fetal size, or macrosomia, is associated with maternal diabetes mellitus, obesity, multiparity, or the large size of one or both parents. If the maternal pelvis is too small, abnormally shaped, or deformed, CPD may be of maternal origin. In this case the fetus may be of average size or even smaller.

Malposition. The most common fetal malposition is persistent occipitoposterior position (i.e., right occipitoposterior or left occipitoposterior), occurring in approximately 25% of all labors. Labor, especially the second stage, is prolonged; the woman typically complains of severe back pain from the pressure of the fetal head (occiput) pressing against her sacrum. Box 24-9 identifles suggested measures to relieve back pain and facilitate rotation of the fetal occiput to an anterior position, which will facilitate birth (Gilbert & Harmon, 1998; Simkin, 1995).


BOX 9 Back Labor—Occiput Posterior Position


Measures to Reduce Back Pain during a Contraction

• Counterpressure: apply fist or heel of hand to sacral area

• Heat or cold applications: apply to sacral area

• Double hip squeeze:

Woman assumes a position with hip joints flexed such as knee-chest

Partner, nurse, or doula places hands over gluteal muscles and presses with palms of hands up and inward toward the center of the pelvis

• Knee press:

Woman assumes a sitting position with knees a few inches apart and feet flat on the floor or on a stool

Partner, nurse, or doula cups a knee in each hand with heels of hands on top of tibia then presses the knees straight back toward the woman's hips while leaning forward toward the woman

Measures to Facilitate the Rotation of the Fetal Head (May Also Relieve Back Pain)

• Lateral abdominal stroking: stroke the abdomen in direction that the fetal head should rotate

• Hands-and-knees position (all-fours): can also be accomplished by kneeling while leaning forward over a birth ball, padded chair seat, bed, or over-the-bed table

• Squatting

• Pelvic rocking

• Stair climbing

• Lateral position: lie on side toward which the fetus should turn

• Lunges: widens pelvis on side toward which woman lunges

Woman stands, facing forward, next to/alongside a chair so that she can lunge toward the side the fetal back is on or in the direction of the fetal occiput

Places foot on seat of chair with toes pointed toward the back of the chair then lunges

Alternative position for lunge: kneeling


Malpresentation. Breech presentation is the most common form of malpresentation, occurring in 3% to 4% of all births and as many as 25°/o of preterm births. There are four main types of breech presentation: frank breech (thighs flexed, knees extended); complete breech (thighs and knees flexed); and two types of incomplete breech, one in which the knee extends below the buttocks and the other in which the foot extends below the buttocks (Fig. 5). Breech presentations are associated with multifetal gestation, preterm birth, fetal and maternal anomalies, hydramnios, and oligohydramnios. Diagnosis is made by abdominal palpation and vaginal examination and usually is confirmed by ultrasound scan (Laros, Flanagan, & Kilpatrick, 1995; Ventura et al, 2001).


Fig. 24-5 Types of breech presentation. A, Frank breech: thighs are flexed on hips; knees are extended. B, Complete breech: thighs and knees are flexed. C, Incomplete breech: foot extends below the buttocks. D, Incomplete breech: knee extends below the buttocks.


During labor, the descent of the fetus in a breech presentation may be slow because the breech is not as good a dilating wedge as the fetal head; the labor itself usually is not prolonged. There is risk of prolapse of the cord if the membranes rupture in early labor. The presence of meconium in amniotic fluid is not necessarily a sign of fetal distress because it results from pressure on the fetal abdominal wall as it traverses the birth canal. Assessment of fetal heart rate (FHR) and pattern should be used to determine whether the passage of meconium is an expected finding associated with breech presentation or is a nonreassuring sign associated with fetal hypoxia. The fetal heart tones of infants in a breech position are best heard at or above the umbilicus.

Vaginal birth is accomplished by mechanisms of labor that manipulate the buttocks and lower extremities as they emerge from the birth canal (Varney, 1997) (Fig. 6). Piper forceps sometimes are used to deliver the head. External cephalic version (ECV) may be tried to turn the fetus to a vertex presentation.


Fig. 6 Mechanism of labor in breech presentation. A, Breech before onset of labor. B, Engagement and internal rotation. C, Lateral flexion. D, External rotation or restitution. E, Internal rotation of shoulders and head. F, Face rotates to sacrum when occiput is anterior. G, Head is born by gradual flexion during elevation of fetal body.


Although opinions vary, a cesarean birth is commonly performed when the fetus is estimated to be larger than 3800 g or smaller than 1500 g, if this is a first pregnancy, if labor is ineffective, or if complications occur (Scott, 1999). Although cesarean birth reduces the risks to the fetus, the maternal risks are increased. ECV also poses risks and is not always successful. Women whose breech presentation occurs late in pregnancy need to be informed of the options for birth, as well as the risks associated with each option.

Face and brow presentations are uncommon and are associated with fetal anomalies, pelvic contractures, and CPD. Vaginal birth is possible if the fetus flexes to a vertex presentation, although forceps often are used. Cesarean birth is indicated if the presentation persists, if there is fetal distress, or if labor stops progressing.

Cesarean birth is usually necessary for a fetus in a shoulder presentation (i.e., the fetus is in a transverse lie), although ECV may be attempted after 38 weeks of gestation (Cunningham et al., 2001; Varney, 1997).

Multifetal pregnancy. Multifetal pregnancy is the gestation of twins, triplets, quadruplets, or more infants. Since 1980, the twin birthrate has increased by 53%. The twin birthrate was 28.9 per 1000 live births in 1999. The higher-order multiple birthrate (i.e., triplet and more) was 184.9 per 100,000 live births in 1999, representing the first decline in what had been a rapid escalation since 1980 (Ventura et al., 2001). It is likely that the rapid escalation was related to use of fertility-enhancing medications and procedures and the older age of childbearing. Refinements in the treatments used to treat infertility may be responsible for the recent decline in higher-order multiple births.

Multiple births are associated with more maternal complications (e.g., dysfunctional labor, hemorrhage) than are single births. The higher incidence of maternal complications and higher risk of perinatal mortality primarily stems from the birth of low-birth-weight infants resulting from preterm birth or IUGR in part related to placental dysfunction and twin-to-twin transfusion. Fetuses may experience distress and asphyxia during the birth process as a result of cord prolapse and the onset of placental separation with the birth of the first fetus.

In addition, fetal complications such as congenital anomalies and abnormal presentations can result in dystocia and an increased incidence of cesarean birth. For example, in only half of all twin pregnancies do both fetuses present in the vertex position, the most favorable for vaginal birth; in one third of the pregnancies, one twin may present in the vertex position and one in the breech (Cunningham et al., 2001; Ellings, Newman, & Bowers, 1998).

The health status of the mother may be compromised by an increased risk for hypertension, anemia, and hemorrhage associated with uterine atony, abruptio placentae, and multiple or adherent placentas. Duration of the phases and stages of labor may vary from the duration experienced with singleton births.

Teamwork and planning are essential components of the management of childbirth in multiple pregnancies. Early detection and care of complications associated with multiple births is essential to achieve a positive outcome for mother and babies. Maternal positioning and active support are used to enhance labor progress and placental perfusion. Emotional support that includes expression of feelings and full explanations of events as they occur and of the status of the mother and the fetuses/newborns is important to reduce the anxiety and stress the mother and her family experience (Ellings, Newman, & Bowers, 1998).


Position of the woman

The functional relationships between the uterine contractions, the fetus, and the mother's pelvis are altered by the maternal position. In addition, the position can provide either a mechanical advantage or disadvantage to the mechanisms of labor by altering the effects of gravity and the body part relationships important to the progress of labor. For example, the hands-and-knees position facilitates rotation from a posterior occiput position more effectively than does the lateral position. Sitting and squatting facilitate fetal descent during pushing and shorten the second stage of labor (Biancuzzo, 1993). Discouraging maternal movement or restricting labor to the recumbent or lithotomy position may compromise progress. The incidence of dystocia in women confined to these positions is increased, resulting in increased need for augmentation of labor or the use of forceps-assisted, vacuum-assisted, or cesarean birth.


Psychologic responses

Hormones released in response to stress can cause dystocia. Sources of stress vary for each woman, but pain and the absence of a support person are two recognized factors. Confinement to bed and restriction of maternal movement can be a source of psychologic stress that compounds the physiologic stress caused by immobility in the nonmedicated laboring woman. When anxiety is excessive, it can inhibit cervical dilation and result in prolonged labor and increased pain perception. Anxiety also causes increased levels of stress-related hormones (e.g., betaendorphin, adrenocorticotropic hormone, cortisol, epinephrine). These hormones act on the smooth muscles of the uterus; increased levels can cause dystocia by reducing uterine contractility (Biancuzzo, 1993).


Abnormal labor patterns

In 1999 prolonged labor patterns occurred at a rate of 7.9 per 1000 live births. The incidence of prolonged labor patterns was slightly higher (i.e., 8.4) among women who were under 20 years of age (Ventura et al., 2001).

Six abnormal labor patterns have been identified and classified by Friedman (1989) according to the nature of the cervical dilation and fetal descent. The labor patterns seen in normal and abnormal labor are described in Table 3.


TABLE 3 Labor Patterns in Normal and Abnormal Labor


1. Dilation: continues

a. Latent phase: <4 cm and low slope

b. Active phase: >5 cm or high slope

c. Deceleration phase >9 cm

2. Descent: active at >9 cm dilation





Prolonged latent phase

>20 hr

>14 hr

Protracted active phase dilation

<1.2 cm/hr

<1.5 cm/hr

Secondary arrest: no change



Protracted descent

<1 cm/hr

<2 cm/hr

Arrest of descent

>1 hr

>V2 hr

Failure of descent

No change during deceleration phase and second stage

Precipitous labor

>5 cm/hr

10 cm/hr


These patterns may result from a variety of causes, including ineffective uterine contractions, pelvic contractures, CPD, abnormal fetal presentations or position, early use of analgesics, conduction anesthesia, and anxiety and stress. Progress in either the first or second stage of labor can be protracted (prolonged) or arrested (stopped). Abnormal progress can be identified by plotting cervical dilation and fetal descent on a labor graph (partogram) at various intervals after the onset of labor and comparing the resulting curve with the expected labor curve for a nulliparous or multiparous labor.

Health care providers must be careful when diagnosing a labor pattern as prolonged and when intervening based on this diagnosis. Criteria defining the differences between false, latent, and active labor should be established. Using hospital admission areas to evaluate a woman's labor status is helpful in preventing the premature implementation of labor interventions such as induction of epidural anesthesia. If a woman is found to be in false or latent (early) labor she can be sent home or remain in the admissions area until labor becomes active (McNiven et al., 1998).

Maternal morbidity and death may occur as a result of uterine rupture, infection, serious dehydration, and postpartum hemorrhage, all possible consequences of abnormal labor patterns. The fetus is at increased risk for hypoxia. A long and difficult labor also can have an adverse psychologic effect on the mother, father, and family.

Precipitous labor. Precipitous labor occurred at a rate of 19.9 per 1000 live births in 1999. Precipitous labor occurred at a slightly higher rate among women ages 35 to 54 and at the lowest rate (i.e., 14.3) among women younger than 20 years of age (Ventura et al., 2001).

Precipitous labor may result from hypertonic uterine contractions that are tetanic in intensity. Maternal and fetal complications can occur as a result. Maternal complications include uterine rupture, lacerations of the birth canal, amniotic fluid embolism, and postpartum hemorrhage. Fetal complications include hypoxia caused by decreased periods of uterine relaxation between contractions and intracranial hemorrhage related to rapid birth (Cunningham et al., 2001).

Women who have experienced precipitous labor often describe feelings of disbelief that their labor began so quickly, alarm that their labor progressed so rapidly, panic about the possibility they would not make it to the hospital on time to give birth, and finally relief when they arrived at the hospital. In addition, women have expressed frustration when nurses would not believe them when they reported their readiness to push. Some women have difficulty remembering the details of their labor and birth and require others, including caregivers, to help them fill in the gaps in their memory (Rippin-Sisler, 1996).


Assessment and Nursing Diagnoses

Risk assessment is a continuous process in the laboring woman. Review of the findings obtained during the initial interview conducted at the woman's admission to the labor unit and ongoing observations of her psychologic response to labor may reveal factors that can be a source of dysfunctional labor. These factors may include anxiety or fear, a complication of pregnancy, or previous labor complications. The initial physical assessment and ongoing assessments provide information about maternal well-being; status of labor in terms of the characteristics of uterine contractions and progress of cervical effacement and dilation; fetal well-being in terms of FHR and pattern, presentation, station, and position; and status of the amniotic membranes. Ultrasound scanning can identify potential dysfunctional labor problems related to the fetus or maternal pelvis. All these assessments contribute to accurate identification of potential and actual nursing diagnoses related to dystocia and maternal-fetal compromise.

Nursing diagnoses that might be identified in women experiencing dystocia include the following:

• Risk for maternal or fetal injury related to

-interventions implemented for dystocia

• Powerlessness related to

-loss of control

• Risk for infection related to

-rupture of membranes

• Ineffective coping related to

-lack of support system


Expected Outcomes of Care

Expected outcomes for the woman who is experiencing dystocia include that the woman will do the following:

• Understand the causes and treatment of dysfunctional labor

• Use measures recommended by the obstetric care team to enhance the progress of labor and birth

• Express relief of pain

• Experience labor and birth with minimal or no complications, such as infection, injury, or hemorrhage

• Give birth to a healthy infant who has not experienced fetal distress

Plan of Care and Interventions

Nurses assume many caregiving roles when labor is complicated. They also work collaboratively with other health care providers in providing care. Interventions that the nurse may implement or assist with include external cephalic version, trial of labor, induction or augmentation with oxytocin, amniotomy, and operative procedures. The nursing role is identified with each of the procedures described.


LEGAL TIP Standard of Care—Labor and Birth Complications

• Document all assessment findings, interventions, and patient responses on patient record and monitor strips according to unit protocols, procedures, and policies and professional standards.

• Assess whether the woman (and her family, if appropriate) is fully informed about procedures for which she is consenting.

• Maintain safety in administering medications and treatments correctly.

• Have verbal orders signed as soon as possible.

• Provide care at the acceptable standard (e.g., according to hospital protocols and professional standards).

• If short staffing occurs in the unit and the nurse is assigned additional patients, the nurse should document that rejecting this additional assignment would have placed these patients in danger as a result of abandonment.

• Maternal and fetal monitoring continues until birth according to the policies, procedures, and protocols of the birthing facility, even when a decision to carry out cesarean birth is made.




Version is the turning of the fetus artificially from one presentation to another and may be done either externally or internally.

External cephalic version. External cephalic version (ECV) is used to attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth. It may be attempted in a labor and birth setting after 37 weeks of gestation. Before it is attempted, ultrasound scanning is done to determine the fetal position; locate the umbilical cord; rule out placenta previa; and assess the amount of amniotic fluid, the fetal age, and the presence of any anomalies. A nonstress test is performed to confirm fetal wellbeing, or the FHR pattern is monitored for a time (usually 10 to 20 minutes). Informed consent is obtained. Contraindications to ECV include uterine anomalies, previous cesarean birth, CPD, placenta previa, multifetal gestation, and oligohydramnios (Cunningham et al., 2001; Laros, Flanagan, & Kilpatrick, 1995).

ECV is accomplished by the exertion of gentle, constant pressure on the abdomen (Fig. 7). A tocolytic agent, such as magnesium sulfate or terbutaline, often is given to relax the uterus and facilitate the maneuver. Ultrasound scanning is done to identify potential problems, such as cord entanglement and placental separation (Cunningham et al., 2001; Laros, Flanagan, & Kilpatrick, 1995).


Fig. 7 External version of fetus from breech to vertex presentation. This must be achieved without force. A, Breech is pushed up out of pelvic inlet while head is pulled toward inlet. B, Head is pushed toward inlet while breech is pulled upward.


During an attempted ECV, the nurse continuously monitors the FHR, especially for bradycardia; checks the maternal vital signs; and assesses the woman's level of comfort because the procedure may cause discomfort. After the procedure is completed, the nurse continues to monitor maternal vital signs, uterine activity, and FHR and assess for vaginal bleeding until the woman's condition is stable. Women who are Rh negative should receive Rh immune globulin because the manipulation can cause fetomaternal bleeding (Cunningham et al., 2001; Laros, Flanagan, & Kilpatick, 1995).

Internal version. With internal version, the fetus is turned by the physician, who inserts a hand into the uterus and changes the presentation to cephalic (head) or podalic (foot). Internal version may be used in multifetal pregnancies to deliver the second fetus. The safety of this procedure has not been documented; maternal and fetal injury is possible. Cesarean birth is the usual method for managing malpresentation in multifetal pregnancies. The nurse's role is to monitor the status of the fetus and to provide support to the woman.


Trial of labor

A trial of labor (TOL) may be initiated if the mother's pelvis is of questionable size or shape, if the fetus is in an abnormal presentation, or if she wishes to have a vaginal birth after a previous cesarean birth. It is a form of care likely to be beneficial when implemented after a previous low segment cesarean birth (Enkin et al., 2001). Fetal sonography or maternal pelvimetry may be done before a TOL to rule out CPD. The cervix must be soft and dilatable. During TOL, the woman is evaluated for the occurrence of active labor, including adequate contractions, engagement and descent of the presenting part, and effacement and dilation of the cervix. Nurses must recognize that the woman and her partner are often anxious about her health and well-being and that of their baby. Supporting and encouraging the woman and her partner and providing information regarding progress can reduce stress, enhance the labor process, and facilitate a successful outcome.


Induction of labor

Induction of labor is the chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about the birth. In 1999 approximately 20% of women who gave birth had their labors induced, a doubling of the labor induction rate in 1990 (Ventura et al., 2001). Induction may be indicated for a variety of medical and obstetric reasons. These include pregnancy-induced hypertension, diabetes mellitus and other medical problems, postterm gestation, suspected fetal jeopardy (e.g., IUGR), logistic factors such as history of previous rapid birth or distance of the woman's home from the hospital, and fetal death. Under such conditions, the risk to the mother or fetus is less than the risk of continuing the pregnancy (Mathews, 1998).

Both chemical and mechanical methods are used to induce labor. Intravenous oxytocin and amniotomy are the most common methods used in the United States. Less commonly used methods include nipple stimulation (manual or with a breast pump), the ingestion of castor oil or herbal preparations, a soap-suds enema, stripping of the membranes, and acupuncture (Summers, 1997). Prostaglandins are also used for inducing labor, but their use for this purpose continues to be investigated (Mastrogiannis & Knuppel, 1995; Summers, 1997).

Success rates for induction of labor are higher when the condition of the cervix is favorable, or inducible. A rating system such as the Bishop score (Table 4) can be used to evaluate inducibility. For example, a score of 9 or more on this 13-point scale might indicate that the cervix is soft (2), anterior (2), 50% or more effaced (1), and dilated 2 cm or more (1) and that the presenting part is engaged (3). Induction of labor is likely to be more successful if the score is 9 or more (Cunningham et al., 2001).


TABLE 4 Bishop Score








Dilation (cm)





Effacement (%)





Station (cm)




+ 1, +2

Cervical consistency





Cervix positior






Cervical ripening methods

Chemical agents. A prostaglandin E2 gel has been approved by the FDA since 1993 as a cervical ripening agent. Currently, preparations of prostaglandin Ej and prostaglandin E2 can used before induction to "ripen" (soften and thin) the cervix (see Medication Guides). This treatment usually results in a higher success rate for the induction of labor, the need for lower dosages of oxytocin during the induction, and shorter induction times. In some cases, women will go into labor after the administration of prostaglandin, thereby eliminating the need to administer oxytocin to induce labor (ACOG, 1995b; Gilbert & Harmon, 1998; Mundle & Young, 1996; Simpson & Poole, 1998; Summers, 1997; Wilson, 2000).


Medication Guide

Cervical Ripening Using Prostagiandin E, (PGE-,): Misoprostol CCytotec)


PGE, ripens the cervix, making it softer and causing it to begin to dilate and efface; stimulates uterine contractions.


PGE, is used for preinduction cervical ripening (ripen cervix before oxytocin induction of labor when the Bishop score is 4 or less) and to induce labor or abortion

(abortifacient agent).


Insert 25 to 50 jxg (1/4 to 1/2 of a 100-/u,g tablet) intravaginally into the posterior fornix using the tips of index and middle fingers without the use of a lubricant. Repeat every 4 to 6 hours as needed to a maximum of 300 to 400 ;u,g in a 24-hour period or until an effective contraction pattern is established (3 or more uterine contractions in 10 minutes), cervix ripens (Bishop score of 8 or greater), or significant adverse reactions occur.

Administer: 50-100 /xg, PO q4-6h (Gl effects increased; may be less effective)


Higher dosages are more likely to result in adverse reactions such as nausea and vomiting, diarrhea, fever, tachysystole (12 or more uterine contractions in 20 minutes without alteration of FHR pattern), hyperstimulation of the uterus (tachysystole with nonreassuring FHR patterns), or fetal passage of meconium.


• Explain procedure to woman and her family. Ensure that an informed consent has been obtained as per agency policy.

• Assess maternal-fetal unit, before each insertion and during treatment following agency protocol for frequency.

Assess maternal vital signs and health status, FHR pattern, and status of pregnancy, including indications for cervical ripening or induction of labor, signs of labor or impending labor, and the Bishop score. Recognize that a nonreassuring FHR pattern; maternal fever, infection, vaginal bleeding, or hypersensitivity; and regular, progressive uterine contractions contraindicate the use of misoprostol.

• Use caution if the woman has a history of asthma, glaucoma, or renal, hepatic, or cardiovascular disorders.

• Have woman void before procedure.

• Assist woman to maintain a supine position with lateral tilt or a side-lying position for 30 to 40 minutes after insertion.

• Prepare to swab vagina to remove unabsorbed medication using a saline soaked gauze wrapped around fingers and to administer terbutaline 0.25 mg subcutaneously or intravenously if significant adverse reactions occur.

• Initiate oxytocin for induction of labor 2 to 4 hours after last dose of misoprostol was administered, following agency protocol, if ripening has occurred and labor has not begun.

• Document all assessment findings and administration procedures.

Misoprostol (Cytotec) has not yet been approved by the FDA for cervical ripening or labor induction.

Medication Guide

Cervical Ripening Using Prostaglandin E2 (PGE2): Dinoprostone (Cervidil Insert; Prepidil Gel)


PGE2 ripens the cervix, making it softer and causing it to begin to dilate and efface; stimulates uterine contractions.


PGE2 is used for preinduction cervical ripening (ripen cervix before oxytocin induction of labor when the Bishop score is 4 or less), and to induce labor or abortion (abortifacient agent)


Place Cervidil insert (10 mg dinoprostone gradually released over 12 hours) intravaginally into the posterior fornix. Insert Prepidil gel (2.5-ml syringe containing 0.5 mg of dinoprostone) into cervical canal just below internal cervical os. Repeat gel insertion in 6 hours as needed to a maximum of 1.5 mg in a 24-hour period.

Continue treatment until maximum dosage is administered or until an effective contraction pattern is established (3 or more uterine contractions in 10 minutes), cervix ripens (Bishop score of 8 or greater), or significant adverse reactions occur.


Potential adverse reactions include headache, nausea and vomiting, diarrhea, fever, hypotension, tachysystole (12 or more uterine contractions in 20 minutes without alteration of FHR pattern), hyperstimulation of the uterus (tachy- systole with nonreassuring FHR patterns), or fetal passage of meconium.


• Explain procedure to woman and her family. Ensure that an informed consent has been obtained as per agency policy.

• Assess maternal-fetal unit, before each insertion and during treatment following agency protocol for frequency. Assess maternal vital signs and health status, FHR pattern, and status of pregnancy, including indications for cervical ripening or induction of labor, signs of labor or impending labor, and the Bishop score. Recognize that a nonreassuring FHR pattern; maternal fever, infection, vaginal bleeding, or hypersensitivity; and regular, progressive uterine contractions contraindicate the use of dinoprostone.

• Use caution if the woman has a history of asthma; glaucoma; or renal, hepatic, or cardiovascular disorders.

• Bring gel to room temperature before administration. Do not force warming process by using a warm water bath or other source of external heat (e.g., microwave).

• Have woman void before insertion.

• Assist woman to maintain a supine position with lateral tilt or a side-lying position for 30 to 60 minutes after insertion of gel or for 2 hours after placement of insert.

• Prepare to swab vagina to remove remaining gel using a saline-soaked gauze wrapped around fingers or pull string to remove insert and to administer terbutaline 0.25 mg subcutaneously or intravenously if significant adverse reactions occur.

• Initiate oxytocin for induction of labor within 6 to 12 hours after last instillation of gel or within 30 minutes after removal of the insert.

• Follow agency protocol for induction if ripening has occurred and labor has not begun.

• Document all assessment findings and administration procedures.

Dinoprostone is the only FDA-approved medication for cervical ripening or labor induction.


Mechanical methods. Hydroscopic dilators (substances that absorb fluid from surrounding tissues and then enlarge) also can be used for cervical ripening. Laminaria tents (natural cervical dilators made from seaweed) and synthetic dilators containing magnesium sulfate (Lamicel) are inserted into the endocervix without rupturing the membranes. As they absorb fluid, they expand and cause cervical dilation. These dilators are left in place for 6 to 12 hours before being removed to assess cervical dilation. Fresh dilators are inserted if further cervical dilation is necessary. Synthetic dilators swell faster than natural dilators and become larger with less discomfort (ACOG, 1995b; Simpson & Poole, 1998; Summers, 1997).

Hydroscopic dilators compare favorably with prostaglandins in terms of their effectiveness in ripening the cervix but are associated with a higher incidence of postpartum maternal and newborn infections. Nursing responsibilities for women who have dilators inserted include documenting the number of dilators and sponges inserted during the procedure, as well as the number removed, and assessment for urinary retention, rupture of membranes, uterine tenderness/pain, contractions, vaginal bleeding, and fetal distress (Gilbert & Harmon, 1998; Simpson & Poole, 1998).

Amniotomy. Amniotomy (artificial rupture of membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if progress begins to slow. Labor usually begins within 12 hours of the rupture; however, if amniotomy does not stimulate labor, the resulting prolonged rupture may lead to infection. Once an amniotomy is performed, the woman is committed to giving birth. For this reason, amniotomy often is used in combination with oxytocin induction. Before the procedure, the woman should be told what to expect; she should also be assured that the actual rapture of the membranes is painless for her and the fetus, although she may experience some discomfort when the Amnihook or other sharp instrument is inserted through the vagina and cervix (see Procedure box).


Procedur Assisting with Amniotomy


Explain to the woman what will be done.

Assess FHR before procedure begins to obtain a baseline reading.

Place several underpads under the woman's buttocks to absorb the fluid.

Position the woman on a padded bed pan, fracture pan, or rolled up towel to elevate her hips.

Assist the health care provider who is performing the procedure by providing sterile gloves and lubricant for the vaginal examination.

Unwrap sterile package containing Amnihook or Allis clamp and pass instrument to the primary health care provider, who inserts it alongside the fingers and then hooks and tears the membranes.

Reassess the FHR.

Assess the color, consistency, and odor of the fluid.

Assess the woman's temperature every 2 hours or per protocol.

Evaluate the woman for signs and symptoms of infection.


Record the following:

Time of rupture

Color, odor, and consistency of the fluid

FHR before and after the procedure

Maternal status (how well procedure was tolerated)


The presenting part of the fetus should be engaged and ell applied to the cervix to reduce the risk of cord prolapse (ACOG, 1995c; Summers, 1997). The membranes are ruptured with an Amnihook or other sharp instrument, and the amniotic fluid is allowed to drain slowly. The color, odor, and consistency of the fluid is assessed for the presence or absence of meconium or blood. The time of rupture is recorded.


NURSE ALERT The FHR is assessed before and immediately after the amniotomy to detect any changes (e.g., variable decelerations) that may indicate cord compression or prolapse.


The woman's temperature should be checked at least every 2 hours to rule out possible infection. If her temperature is 38° C or higher, the physician or nurse-midwife should be notified. The nurse assesses for other signs and symptoms of infection, such as maternal chills, fetal tachycardia, uterine tenderness on palpation, and foul-smelling vaginal drainage (Simpson & Poole, 1998). Comfort measures, such as frequently changing the woman's underpads, and perineal cleansing are implemented.

Oxytocin. Oxytocin is a hormone normally produced by the posterior pituitary gland; it stimulates uterine contractions. It may be used either to induce labor or to augment a labor that is progressing slowly because of inadequate uterine contractions.

The indications for oxytocin induction or augmentation of labor may include, but are not limited to, the following:

• Suspected fetal jeopardy (e.g., IUGR)

• Inadequate uterine contractions; dystocia

• Premature rupture of membranes

• Postterm pregnancy

• Chorioamnionitis

• Maternal medical problems (e.g., woman with severe Rh isoimmunization, diabetes, renal disease, or chronic pulmonary disease)

• Pregnancy-induced hypertension

• Fetal demise (death)

• Multiparous women with a history of precipitous labor or who live far from the hospital

The management of stimulation of labor is the same regardless of the indication. Because of the potential dangers associated with the injection of oxytocin in the prenatal and intrapartal periods, the FDA has issued certain restrictions to its use. Contraindications to oxytocin stimulation of labor include, but are not limited to, the following:

• CPD, prolapsed cord, transverse lie

• Nonreassuring FHR

• Placenta previa or vasa previa

• Prior classic uterine incision or uterine surgery

• Active genital herpes infection

• Invasive cancer of the cervix

Certain maternal and fetal conditions, although not contraindications to the use of oxytocin to stimulate labor, do require special caution during its administration. These conditions include the following:

• Multifetal presentation

• Breech presentation

• Presenting part above the pelvic inlet

• Abnormal FHR pattern not requiring emergency birth

• Polyhydramnios

• Grand multiparity

• Maternal cardiac disease; hypertension

Oxytocin use can present hazards to the mother and fetus. These hazards are primarily dose related, with most problems caused by high doses that are given rapidly. Maternal hazards include water intoxication and tumultuous labor with tetanic contractions, which may cause premature separation of the placenta, rupture of the uterus, lacerations of the cervix, or postpartum hemorrhage. These complications can lead to infection, disseminated intravascular coagulation, or amniotic fluid embolism. Women may become anxious or fearful if the induction is not successful because they may then have concerns about the method of birth.

Uterine hyperstimulation reduces the blood flow through the placenta and results in FHR decelerations (bradycardia, diminished variability, late decelerations), fetal asphyxia, and neonatal hypoxia. If the estimated date of birth is inaccurate, physical injury, neonatal hyperbilirubinemia, and prematurity are other hazards.

The physician or nurse-midwife writes the order for the induction or augmentation of labor with oxytocin. The nurse implements the order by initiating the primary intravenous infusion and administering the oxytocin solution through a secondary line. The nurse's actions related to assessment and care of a woman whose labor is being induced are guided by hospital protocol and professional standards (Fig. 8 and Box 10).


Fig, 8 Woman in side-lying position receiving oxytocin. (Courtesy Michael S. Clement, MD, Mesa, AZ.)


BOX 10 Protocol: Induction of Labor with Oxytocin


Explain technique, rationale, and reactions to expect:

• Route and rate for administration of medication

• What "piggyback" is for

• Reasons for use:

Induce labor, improve labor

• Reactions to expect concerning the nature of contractions: the intensity of contraction increases more rapidly, holds the peak longer, and ends more quickly; contractions will come regularly and more often

• Monitoring to anticipate:

Maternal: blood pressure, pulse, uterine contractions, uterine tone

Fetal: heart rate, activity

• Success to expect: a favorable outcome will depend on inducibility of the cervix (e.g., Bishop score of 9)

• Keep woman and support person informed of progress



Position woman in side-lying or upright position

Assess status of maternal fetal unit

Prepare solutions and administer with pump delivery system according to prescribed orders:

• Infusion pump and solution are set up (e.g., 10 U/1000 ml isotonic electrolyte solution)

• Piggyback solution is connected to IV line at proximal port (port nearest point of venous insertion)

• Solution with oxytocin is flagged with a medication label

• Begin induction at 0.5 to 2 mU/min

• Increase dose 1 to 2 mU/min at intervals of 15 to 60 minutes until a dose of up to 20 to 40 mU/min is reached


• Intensity of contractions results in intrauterine pressures of 40 to 90 mm Hg (shown by internal monitor)

• Duration of contractions is 40 to 90 seconds

• Frequency of contractions is 2- to 3-minute intervals

• Cervical dilation of 1 cm/hr in the active phase


• Monitor blood pressure, pulse, and respirations every 30 to 60 minutes and with every increment in dose

• Monitor contraction pattern and uterine resting tone every 15 minutes and with every increment in dose

• Assess intake and output; limit IV intake to 1000 ml/8 hr; output should be 120 ml or more every 4 hours

• Perform vaginal examination as indicated

• Monitor for nausea, vomiting, headache, hypotension

• Assess fetal status using electronic fetal monitoring; evaluate tracing every 15 minutes and with every increment in dose

• Observe emotional responses of woman and her partner


• Uterine hyperstimulation

• Nonreassuring FHR pattern

• Suspected uterine rupture

• Inadequate uterine response at 20 mU/min


Discontinue use of oxytocin per hospital protocol:

• Turn woman on her side

• Increase primary IV rate up to 200 ml/hr, unless patient has water intoxication, in which case, the rate is decreased to one that keeps the vein open

• Give woman oxygen by face mask at 8 to 10 L/min or per protocol or physician's or nurse-midwife's order


• Medication: kind, amount, time of beginning, increasing dose, maintaining dose, and discontinuing medication in patient record and on monitor strip

• Reactions of mother and fetus

Pattern of labor

Progress of labor

FHR and pattern

Maternal vital signs

Nursing interventions and woman's response

• Notification of physician or nurse-midwife


In the past the aim of induction has been to achieve a contraction pattern that simulates the active phase of labor as quicldy as possible. However, research on uterine tolerance to oxytocin has shown that lower doses given over a longer time are as effective as previous protocols and are less likely to cause uterine hyperstimulation and dysfunctional labor (ACOG, 1995b; Simpson & Poole, 1998; Summers, 1997).

Nursing considerations. A written protocol for the preparation and administration of oxytocin should be established by the obstetric department (physicians, nurses) in each institution. One procedure recommended for a woman who is eligible for induction of labor is discussed in Box 10.


NURSE ALERT Oxytocin is discontinued immediately and the primary health care provider notified if uterine hyperstimulation or nonreassuring FHR (or both) occurs.


Other nursing interventions, such as administering oxygen by face mask, positioning the woman on her side, and infusing more intravenous fluids, are implemented immediately (see Emergency box). Based on the status of the maternal-fetal unit, the physician or nurse-midwife may order that the infusion be restarted once the FHR and uterine activity return to acceptable levels (ACOG, 1995b).





Uterine contractions lasting more than 90 seconds and occurring more frequently than every 2 minutes

Uterine resting tone greater than 20 mm Hg

Nonreassuring FHR:

Abnormal baseline (<110 or >160 beats/min)

Absent variability

Repeated late decelerations or prolonged decelerations


Maintain woman in side-lying position

Turn off oxytocin infusion; keep maintenance IV line open; increase rate

Start administering oxygen by face mask, per protocol or physician's order

Notify primary health care provider

Prepare to administer terbutaline (Brethine) 0.25 mg subcutaneously if ordered to decrease uterine activity

Continue monitoring FHR and uterine activity

Document responses to actions


Augmentation of labor

Augmentation of labor is usually implemented for the management of hypotonic uterine dysfunction resulting in a slowing of the labor process (protracted active phase). Common augmentation methods include oxytocin infusion, amniotomy, and nipple stimulation. Noninvasive methods such as emptying the bladder, ambulation and position changes, relaxation measures, nourishment and hydration, and hydrotherapy should be attempted before invasive interventions are initiated. The administration procedure and nursing assessment and care measures for augmentation of labor using oxytocin are similar to those used for induction of labor with oxytocin (Gilbert & Harmon, 1998; Pozaic, 1999; Simpson & Poole, 1998).

Some physicians advocate active management of labor, that is, the augmentation of labor to establish efficient labor with the aggressive use of oxytocin (e.g., a starting dose of 6 mU/min with increases of 6 mU/min every 15 minutes to a maximum dose of 40 mU/min) to shorten labor (ACOG, 1995c).

Additional components of the active management of labor include strict criteria to diagnose that the woman is in active labor with 100% effacement, amniotomy within 1 hour of admission of a woman in labor if spontaneous rupture of the membranes has not occurred, and continuous presence of a nurse who provides one-on-one care for the woman while she is in labor. When all components are fully implemented, active management of labor is associated with a lower incidence of cesarean birth (ACOG, 1995c). Active management of labor continues to be under study in the United States to determine effectiveness and impact on perinatal morbidity and mortality rates. Thus far results have been disappointing, especially in terms of a lack of reduction in the rate of cesarean birth. The disappointing results have been attributed, in part, to a greater than one-to-one nurse-patient ratio and the high rate of epidural anesthesia. It is considered to be a form of care of unknown effectiveness (Enkin et al., 2001; Gilbert & Harmon, 1998; Simpson & Poole, 1998).


Forceps-assisted birth

A forceps-assisted birth uses an instrument with two curved blades to assist in the birth of the fetal head. The cephalic-like curve of the forceps commonly used is similar to the shape of the fetal head, with a pelvic curve to the blades conforming to the curve of the pelvic axis. The blades are joined by a pin, screw, or groove arrangement. These locks prevent the forceps from compressing the fetal skull. Maternal indications for forceps-assisted birth include the need to shorten the second stage of labor in the event of dystocia or to compensate for the woman's deficient expulsive efforts (e.g., if she is tired or has been given spinal or epidural anesthesia) or to reverse a dangerous condition (e.g., cardiac decompensation).

Fetal indications include birth of a fetus in distress, certain abnormal presentations, arrest of rotation, or to deliver the head in a breech presentation. The use of forceps during childbirth has been decreasing. In 1999 forceps were used to assist 2.3% of births compared with 5.5% in 1989 (Ventura et al., 2001).

Certain conditions are required for a forceps-assisted birth to be successful. The woman's cervix must be fully dilated to avert lacerations and hemorrhage. The bladder should be empty. The presenting part must be engaged, and a vertex presentation is desired. Membranes must be ruptured so that the position of the fetal head can be determined and the forceps can firmly grasp the head during birth (Fig. 9). In addition, CPD should not be present.


Fig. 9 Outlet forceps-assisted extraction of the head.


Nursing considerations. The nurse obtains the type of forceps requested by the physician. The nurse may explain to the mother that the forceps blades fit like two tablespoons around an egg, with the blades coming over the baby's ears.


NURSE ALERT Because compression of the cord between the fetal head and the forceps would cause a drop in FHR, the FHR is assessed, reported, and recorded before and after application of the forceps.


If a drop in FHR occurs, the physician would then remove and reapply the forceps. Ordinarily, traction is applied during contractions.

After birth, the mother is assessed for vaginal and cervical lacerations (e.g., bleeding that occurs even with a contracted uterus); urine retention, which may result from bladder injuries; and hematoma formation in the pelvic soft tissues, which may result from blood vessel damage. The infant should be assessed for bruising or abrasions at the site of the blade applications, facial palsy resulting from pressure of the blades on the facial nerve (cranial nerve VII), and subdural hematoma. Newborn and postpartum caregivers should be told that the birth was forceps assisted.


Vacuum-assisted birth

Vacuum-assisted birth, or vacuum extraction, is a birth method involving the attachment of a vacuum cup to the fetal head, using negative pressure to assist in the birth of the head. Indications for its use are similar to those for outlet forceps. Prerequisites for use include a vertex presentation, ruptured membranes, and absence of CPD (Cunningham et al, 2001).

The rate of use of the vacuum extractor was 5.1% in 1999 (Ventura et al., 2001). When an operative vaginal birth is required, vacuum assistance is preferred as a more beneficial form of care than forceps assistance (Enkin et al., 2001).

When the birth is to be vacuum assisted, the woman is prepared for a vaginal birth in the lithotomy position to allow for sufficient traction. The cup is applied to the fetal head, and a caput develops inside the cup as the pressure is initiated (Fig. 10). Traction is applied to facilitate descent of the fetal head, and the woman is encouraged to push as suction is applied. As the head crowns, an episiotomy is performed if necessary. The vacuum cup is released and removed after birth of the head. If vacuum extraction is not successful, a forceps-assisted or cesarean birth is then performed.



Fig. 10 Use of vacuum extraction to rotate fetal head and assist with descent. A, Arrow indicates direction of traction on the vacuum cup. B, Caput succedaneum formed by the vacuum cup.


Risks to the newborn include cephalhematoma, scalp lacerations, and subdural hematoma. Fetal complications can be reduced by strict adherence to the manufacturer's recommendations for method of application, degree of suction, and duration of application. Maternal complications are uncommon but can include perineal, vaginal, or cervical lacerations and soft tissue hematomas.

Nursing considerations. The nurse's role for the woman who has a vacuum-assisted birth is one of support person and educator. The nurse can prepare the woman for birth and encourage her to remain active in the birth process by pushing during contractions. The FHR should be assessed frequently during the procedure. After birth, the newborn should be observed for signs of trauma and infection at the application site and for cerebral irritation (e.g., poor sucking or listlessness). The newborn may be at risk for cephalhematoma and neonatal jaundice as bruising resolves. The parents may need to be reassured that the caput succedaneum will begin to disappear in a few hours. Neonatal caregivers should be told that the birth was vacuum assisted.


Cesarean birth

The purpose of cesarean birth is to preserve the life or health of the mother and her fetus; it may be the best choice for birth when there is evidence of maternal or fetal complications. Since the advent of modern surgical methods and care, and the use of antibiotics, maternal and fetal morbidity and mortality rates have decreased. In addition, incisions are made into the lower uterine segment rather than into the muscular body of the uterus and thus promote more effective healing. However, despite these advances, cesarean birth still poses threats to the health of the mother and infant.

The incidence of cesarean births has increased from less than 5% in 1965 to 22% in 1999. Factors cited as sources of this increase include use of electronic fetal monitoring and epidural anesthesia; an increase in the number of firsttime pregnancies, as well as pregnancies at an older age; and the high incidence of repeat cesarean births. Between 1998 and 1999 the rate increased by 4%. This increase in cesarean birthrate is most likely associated with a decrease in the rate of vaginal birth after cesarean (VBAC). After increasing from 18.9% in 1989 to 28.3% in 1996, the rate of VBAC declined to 23.4% in 1999 (Guyer et al., 1998; Ventura et al., 2001).

Women 35 years of age and older had a cesarean birthrate of 30% in 1999, approximately twice the rate for women younger than 20 years of age (Ventura et al., 2001). Women who have private insurance, are of a higher socioeconomic status, or deliver in a private hospital are more likely to experience cesarean birth than are women who are poor, have no insurance, are receiving public assistance (e.g., Medicaid), or deliver in public hospitals (DiMatteo et al., 1996; Porreco & Thorp, 1996; Scott, 1999).

Approaches for the management of labor and birth to reduce the rate of cesarean birth and increase the rate of VBAC are presented in Box 11. These management approaches involve the combined efforts of health care professionals and pregnant women and their families (Flamm, Berwick, & Kabcenell, 1998; McNiven et al., 1998).


BOX 11 Selected Measures to Reduce Cesarean Birth Rate and Increase Rate of VBAC


• Advantages and safety of the home environment for early or latent labor

• Indicators for hospital admission

• Management techniques to use during labor to enhance progress

• Nonpharmacologic measures to reduce pain and discomfort and enhance relaxation

• Safety and effectiveness of TOL and VBAC


• Distinguish clinical manifestations for false labor, latent/ early labor, and active labor

• Conduct admission assessments in a separate admissions area

• Send women in false or early/latent labor home or keep them in the admissions area

• Admit women in active labor to the labor and birth unit


• Determine status of the maternal-fetal unit

• Establish an individualized rationale for initiating labor interventions such as epidural anesthesia, induction/ augmentation, amniotomy, cesarean birth


• Schedules admission during active labor

• Avoids automatic interventions such as routine induction for spontaneous rupture of membranes at term or postterm pregnancy and cesarean birth for breech presentation, twin gestation, genital herpes, or failure to progress

• Relies on assessment findings reflective of the status of the maternal-fetal unit rather than strict adherence to set ranges for the duration of the stages and phases of labor

• Employs intermittent rather than continuous electronic fetal monitoring of low risk pregnant women

• Focuses on measures that are known to enhance the progress of labor such as upright positions, frequent position changes, ambulation, oral nutrition and hydration, relaxation techniques, hydrotherapy

• Emphasizes nonpharmacologic measures to relieve pain

• Uses nonpharmacologic measures in a manner that reduces their labor-inhibiting effects

• Establishes criteria for elective cesarean birth and TOL

• Encourages women who have had a previous cesarean birth to participate in TOL to attempt a vaginal birth


The type of nursing care given may also influence the rate of cesarean births. Radin, Harmon, and Hanson (1993) found that cesarean rates were lower for women whose nurses provided supportive care during labor. A labor management approach that uses one-to-one support and emphasizes ambulation, maternal position changes, relaxation measures, oral fluids and nutrition, hydrotherapy, and nonpharmacologic pain relief facilitates the progress of labor and reduces the incidence of dystocia (Albers, Lydon-Rochelle, & Krulewitch, 1995; Porreco & Thorp, 1996). The labor management approach that most consistently reduced cesarean birthrate was one-to-one support of the laboring woman by another female such as a nurse, nurse-midwife, or doula (Cefalo & Bowes, 1998; Gabay & Wolfe, 1997).

Indications. There are few absolute indications for cesarean birth. Today, most cesarean births are performed primarily for the benefit of the fetus. The most common indications for cesarean birth are related to labor and birth complications. The complications most closely associated with cesarean birth include fetal distress, CPD, malpresentations such as breech and shoulder, placental abnormalities (previa, abruptio), umbilical cord prolapse, dysfunctional labor pattern, and multiple gestation. Medical risk factors most closely associated with cesarean birth include hypertensive disorders, active genital herpes, and diabetes (Porreco & Thorpe, 1996; Ventura et al, 2001).

Ethical consideration: forced cesarean birth. A woman's refusal to undergo cesarean birth for fetal reasons is often described as a maternal-fetal conflict. Health care providers are ethically obliged to protect the well-being of both the mother and the fetus; a decision for one affects the other. If a woman refuses a cesarean birth that is recommended because of fetal jeopardy, health care providers need to make every effort to find out why she is refusing and provide information that may persuade her to change her mind. If the woman continues to refuse surgery, health care providers must decide if it is ethical to get a court order for the surgery; however, every effort should be made to avoid this legal step.

Surgical techniques. The two main types of cesarean operation are the classic and the lower-segment cesarean incisions. Classic cesarean birth is rarely performed today, although it may be used when rapid birth is necessary and in some cases of shoulder presentation and placenta previa. The incision is made vertically into the upper body of the uterus (Fig. 11, A). Because the procedure is associated with a higher incidence of blood loss, infection, and uterine rupture in subsequent pregnancies than is lowersegment cesarean birth, vaginal birth after a classic cesarean birth is contraindicated.


Fig . 11 Cesarean birth; skin and uterine incisions. A, Classic: vertical incisions of skin and uterus. B, Low cervical: horizontal incision of skin; vertical incision of uterus. C, Low cervical: horizontal incisions of skin and uterus.


Lower-segment cesarean birth can be achieved through a vertical or transverse incision into the uterus (Fig. 11,B and C). The transverse incision is more popular because it is easier to perform, is associated with less blood loss and fewer postoperative infections, and is less likely to rupture in subsequent pregnancies (Cunningham et al., 2001; Scott, 1999).

Complications and risks. Cesarean births are not without complications, for both the mother and fetus. Maternal complications occur in 25% to 50% of births and include aspiration, pulmonary embolism, wound infection, wound dehiscence, thrombophlebitis, hemorrhage, urinary tract infection, injuries to the bladder or bowel, and complications related to anesthesia. There also is a risk that the fetus will be born prematurely if the gestational age has not been accurately determined; fetal injuries can occur during the surgery (Scott, 1999). Besides these risks, the woman is at economic risk because the cost of cesarean birth is higher than that of vaginal birth and a longer recovery period may require additional expenditures.

Following a cesarean birth, women may experience a delay in their ability to interact with their newborns after birth is delayed. These women are less likely to breastfeed and may even have some difficulty expressing positive feeling about their newborns for some time after birth. They are often less satisfied with their childbirth experience and report more fatigue and poor physical functioning during the first few weeks after discharge. These reactions are more pronounced among women who had unplanned or emergency cesarean birth (DiMatteo et al., 1996).

Anesthesia. Spinal, epidural, and general anesthetics are used for cesarean births. Epidural blocks are popular because women want to be awake for and aware of the birth experience. However, the choice of anesthetic depends on several factors. The mother's medical history or present condition, such as a spinal injury or hemorrhage, may rule out the use of regional anesthesia. Time is another factor, especially if there is an emergency and the life of the mother or infant is at stake. In such a case, general anesthesia will most likely be used unless an epidural block is already in place. The woman may not know all the options or may have fears about "a needle in her back" or of being awake and feeling pain. She needs to be fully informed about the risks and benefits of the different types of anesthesia so that she can participate in the decision whenever there is a choice.

Scheduled cesarean birth. Cesarean birth is scheduled or planned if labor is contraindicated (e.g., complete placenta previa), if birth is necessary but labor is not inducible (e.g., hypertensive states, which cause a poor intrauterine environment that threatens the fetus), or if this has been decided on by the physician and the woman (e.g., a repeat cesarean birth).

Women who are scheduled to have a cesarean birth have time to prepare for it psychologically. However, the psychologic responses of these women may differ. Those having a repeat cesarean birth may have disturbing memories of the conditions preceding the initial surgical birth and of their experiences in the postoperative recovery period. They may be concerned about the added burdens of caring for an infant and perhaps other children while recovering from a surgical operation. Others may feel glad that they have been relieved of the uncertainty about the date and time of the birth and to be free of the pain of labor.

Unplanned cesarean birth. The psychosocial outcomes of unplanned or emergency cesarean birth are usually more pronounced and negative in nature when compared with the outcomes associated with a scheduled or planned cesarean birth (DiMatteo et al., 1996). Women and their families experience abrupt changes in their expectations for birth, postbirth care, and the care of the new baby at home. This may be an extremely traumatic experience for all.

The woman usually approaches the procedure tired and discouraged after an ineffective and difficult labor. Fear predominates as she worries about her own safety and well-being and that of her fetus. She may be dehydrated, with low glycogen reserves. Because preoperative procedures must be done quickly and competently, the time for explanation of the procedures and operation is often short. Because maternal and family anxiety levels are high at this time, much of what is said may be forgotten or misunderstood. The woman may experience feelings of anger or guilt in the postpartum period. Fatigue is often noticeable in these women, and they need much supportive care.

After surgery, therefore, time must be spent reviewing the events preceding the operation and the operation itself to ensure that the woman understands what has happened and that gaps in her recollections are filled. This approach will help create more realistic memories of the childbirth experience, thereby having a more positive influence on future pregnancies and labors (Ryding, Wijma, & Wijma, 1998).

Whether cesarean birth is planned (scheduled) or unplanned (emergency), the loss of the experience of giving birth to a child in the traditional manner may have a negative effect on a woman's self-concept. An effort is therefore made to maintain the focus on the birth of a child rather than on the operative procedure.

Prenatal preparation. Concerned professional and lay groups in the community have established councils for cesarean birth to meet the needs of these women and their families. Such groups advocate that a discussion of cesarean birth be included in all parenthood preparation classes. No woman can be guaranteed a vaginal birth, even if she is in good health and there is no indication of danger to the fetus before the onset of labor. For this reason, every woman needs to be aware of and prepared for this eventuality.

Childbirth educators stress the importance of emphasizing the similarities and differences between a cesarean and vaginal birth. In support of the philosophy of family centered birth, many hospitals have instituted policies that permit fathers and other partners and family members to share in these births as they do in vaginal ones. Women who have undergone cesarean birth agree that the continued presence and support of their partners helped them respond positively to the entire experience. In addition to preparing women for the possibility of cesarean birth, childbirth educators should empower women to believe in their ability to give birth vaginally and to seek care measures during labor that will enhance the progress of their labors and reduce their risk for cesarean birth.

Preoperative care. Family-centered care is the goal for the woman who is to undergo cesarean birth and for her family. The preparation of the woman for cesarean birth is the same as that done for other elective or emergency surgery. The primary health care provider discusses, with the woman and her family, the need for the cesarean birth and the prognosis for the mother and infant. The anesthesiologist assesses the woman's cardiopulmonary system and describes the options for anesthesia. Informed consent is obtained for the procedure.

Blood and urine tests are usually done the day before a planned cesarean birth or on admission to labor. Laboratory tests, most commonly ordered to establish baseline data, include a complete blood cell count and chemistry, blood typing and crossmatching, and urinalysis. Maternal vital signs and blood pressure and FHR continue to be assessed per the hospital routine until the operation begins. Physical preoperative preparation usually includes inserting a retention catheter to keep the bladder empty and administering prescribed preoperative medications. An abdominal-mons shave or a clipping of pubic hair may be performed. An antacid, administered orally to neutralize gastric secretions in case of aspiration, is a beneficial form of care (Enkin et al., 2001). Intravenous fluids are started to maintain hydration and to provide an open line for the administration of blood or medications if needed.

Removal of dentures, nail polish, and jewelry may be optional, depending on hospital policies. If the woman wears glasses and is going to be awake, the nurse should make sure her glasses accompany her to the operating room so she can see her infant. If the woman wears contact lenses, the nurse can find out whether they can be worn for the birth.

During the preoperative preparation the support person is encouraged to remain with the woman as much as possible to provide continuing emotional support (if this action is culturally acceptable to the woman and support person). The nurse provides essential information about the preoperative procedures during this time. Although the nursing actions may be carried out quickly if a cesarean birth is unplanned, verbal communication, particularly explanations, is important. Silence can be frightening to the woman and her support person. The nurse's use of touch can communicate feelings of care and concern for the woman. The nurse can assess the woman's and her partner's perceptions about cesarean birth (e.g., the woman feels that she is a failure because she did not have a vaginal birth). If there is time before the birth, the nurse can teach the woman about postoperative expectations and about pain relief, turning, coughing, and deep-breathing measures.

Intraoperative care. Cesarean births occur in operating rooms in the surgical suite or in the labor and birth unit. Once the woman has been taken to the operating room, her care becomes the responsibility of the obstetric team, surgeon, anesthesiologist, pediatrician, and surgical nursing staff (Fig. 12). If possible, the partner, who is gowned appropriately, accompanies the woman to the operating room and remains close to her so that continued support and comfort can be provided.





Fig. 12 Cesarean birth. A, "Bikini" incision has been made, the muscle layer is separated, the abdomen is entered, and the uterus has been exposed and incised; suctioning of amniotic fluid continues as head is brought up through the incision. Note small amount of bleeding. B, The neonate's birth through the uterine incision is nearly complete. C, A quick assessment is performed; note extreme molding of head resulting from cephalopelvic disproportion. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)


The nurse who is circulating may assist with positioning the woman on the birth (surgical) table. It is important to position her so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is usually accomplished by placing a wedge under the hip. A Foley catheter is inserted into the bladder at this time if one is not already in place.

If the partner is not allowed or chooses not to be present, the nurse can stay in communication with him or her and give progress reports whenever possible. If the woman is awake during the birth, the nurse or anesthesiologist, or both, can tell her what is happening and provide support. She may be anxious about the sensations she is experiencing, such as the coldness of solutions used to prepare the abdomen and pressure or pulling during the actual birth of the infant. She also may be apprehensive because of the bright lights or the presence of unfamiliar equipment and masked and gowned personnel in the room. Explanations by the nurse can help decrease the woman's anxiety.

Care of the infant usually is delegated to a pediatrician or a nurse team skilled in neonatal resuscitation, because these infants are considered to be at risk until there is evidence of physiologic stability after the birth.

A crib with resuscitation equipment is readied before surgery. Those responsible for care are expert not only in resuscitative techniques but also in their ability to detect normal and abnormal infant responses. After birth, if the infant's condition permits, the baby can be given to the woman's partner to hold. If the mother is awake, she can see and touch the baby (Fig. 13). The infant whose condition is compromised is transported after initial stabilization to the nursery for observation and the implementation of appropriate interventions. In some institutions the partner may accompany the infant; if not, personnel keep the family informed of the infant's progress and parentinfant contacts are initiated as soon as possible.


Fig. 13 A, Parents and their newborn. The physician manually removes the placenta, suctions the remaining amniotic fluid and blood from the uterine cavity, and closes the uterine incision, peritoneum, muscle layer, fatty tissue, and finally the skin, while the new family shares some time together. B, Parents become better acquainted with their newborn while mother rests after surgery. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)


If the family cannot accompany the woman during surgery, the family is directed to the surgical or obstetric waiting room. The physician then reports on the condition of the mother and child to the family members after the birth is completed. Family members may accompany the infant as she or he is transferred to the nursery, giving them an opportunity to see and admire the new baby.

Immediate postoperative care. Once surgery is completed, the mother is transferred to a recovery room or back to her labor room. Women who have experienced a cesarean birth have both postoperative and postpartum needs that must be addressed. They are surgical patients, as well as new mothers (Eakes & Brown, 1998). Nursing assessments in this immediate postbirth period include degree of recovery from the effects of anesthesia, postoperative and postbirth status, and degree of pain. A patent airway is maintained, and the woman is positioned to prevent possible aspiration. Vital signs are taken every 15 minutes for 1 to 2 hours, or until stable. The condition of the incisional dressing, the fundus, and the amount of lochia are assessed, as well as the intravenous intake and the urine output through the Foley catheter. The woman is helped to turn and do coughing, deep-breathing, and leg exercises. Medications to relieve pain may be administered. If the baby is present, the mother and her partner are given some time alone with him or her to facilitate bonding and attachment. Breastfeeding can be initiated if the mother feels like trying. If the woman is in a recovery area, she usually is transferred to her postpartum room after 1 to 2 hours, or once her condition is stable and the effects of anesthesia have worn off (i.e., she is alert, oriented, and able to feel and move extremities) (see Care Path).


CARE PATH Cesarean Birth without Complications: Expected Length of Stay—48 to 72 Hours





25 TO 48 HOURS



Recovery room/PACU admission assessment completed

PP admission assessment and care plan completed




Vital Signs

q15min x 1 hr; q30min x 4 hr, WNL

q1h X 3, WNL

q4-8h, WNL

q8h, WNL

q8h, WNL

Postpartum Assessment

q15min x 1 hr, WNL

q1h X 3, WNL

q8h, WNL

q8-12 h, WNL

q8-12 h, WNL

Abdominal Incision

Dressing dry and intact

Dressing dry and intact

Dressing dry and intact

Dressing off or changed, incision intact

Incision intact; staples may be removed and Steri-Strips in place, incision WNL


Retention catheter output >30 ml/hr

Retention catheter output >30 ml/hr

Retention catheter output >30 ml/hr

Catheter discontinued, output >100 ml/void or 240 ml/8 hr

Urine output >240 ml/8 hr



Absent or hypoactive BS

Hypoactive to active BS

Active BS + flatus

Active BS + flatus; may or may not have BM


Alert or easily aroused, can move legs

Alert and oriented, moving all extremities

Ambulating with help

Ambulating unassisted

Ambulating ad lib


Evidence of parentinfant bonding; first breastfeeding if desired


Parent-infant bonding continues

Parent-infant bonding progressing


Laboratory Tests



Intrapartal CBC results on chart/computer; determine Rh status and need for anti-Rh globulin; check for rubella immunity

PP HCT WNL, all lab results on chart, give anti-Rh globulin if indicated

Give rubella vaccine if indicated



IV continues

IV continues

IV continues

IV may be discontinued




Ice chips, sips of clear liquids

Clear liquids

Regular diet or as tolerated

Regular diet



Pericare by nurse

Pericare with help




Bed rest

Bed rest

00B x 3 with help, ADLs assisted. assisted to comfortable position to hold and feed baby

Holds baby comfortably, ambulates without assistance, ADLs unassisted

Activity ad lib

Pulmonary Care

Patent airway; 02 discontinued

TCDB q2h with splinting, incentive spirometry q1h if ordered, lungs clear

TCDB q2h while awake; lungs clear

TCDB as needed; lungs clear



Oxytocin added to IV


Pain control: analgesics, IV, or epidural narcotic


Oxytocin continued


Pain control: analgesics—PCA, IM, PO, or epidural narcotic

Oxytocin may be discontinued

Pain control: IM, PO, PCA narcotics or analgesics

Oxytocin discontinued

Pain control: PO analgesics, NSAIDs PCA discontinued; stool softener, PNV




Rx filled or given ; to take home

Teaching, Discharge Plan

Breastfeeding, positioning,

leg exercises

Verbalize understanding/ unit routines, how to achieve rest, TCDB, involution, pain control

Self: comfort measures and care; reinforce TCDB and positioning; introduce teaching videos, lactation promotion or suppression

Infant: Handwashing, infant safety. positioning for feeding and burping; if breastfeeding. then positioning baby, latching on, timing, removing from breast

Self: diet; activity/rest; bowel/bladder function

Infant: bonding; parent concerns; feeding; infant bath, cord care; need for car seat; newborn characteristics; circumcision, if requested; answer questions

Self: home care, signs of complications (infections, bleeding), normal psychologic adjustments, normal ADLs; resumption of sexual activities; contraception; identification of support system at home; selfconcept issues related to cesarean birth. Inform whom to call if problems; review need to keep follow-up appointment; provide information about community resources; provide copy of home care

Infant: parents to demonstrate infant care; reinforce use of booklets for infant care, whom to call if problems; discuss immunization needs; review need to keep follow-up appointments


Postoperative/postpartum care. The attitude of the nurse and other health team members can influence the woman's perception of herself after a cesarean birth. The caregivers should stress that the woman is a new mother first and a surgical patient second. This attitude helps the woman perceive herself as having the same problems and needs as other new mothers while at the same time requiring supportive postoperative care.

The women's physiologic concerns for the first few days may be dominated by pain at the incision site and pain resulting from intestinal gas, and hence the need for pain relief. If epidural anesthesia was used for the surgery, epidural narcotics can be given in the recovery period to provide pain relief for approximately 24 hours. Otherwise, pain medications usually are given every 3 to 4 hours, or patientcontrolled analgesia may be ordered instead. Other comfort measures such as position changes, splinting of the incision with pillows, and relaxation techniques may be implemented. Women are often the best judges of what their bodies need and can tolerate, including the postoperative ingestion of foods and fluids. If desired by the woman, the early introduction of solid food is safe. Women who eat early have been found to require less analgesia and have fewer gastrointestinal problems (Burrows et al., 1995). Ambulation and rocking in a rocking chair may relieve gas pains, and avoiding the consumption of gas-forming foods and carbonated beverages may help minimize them (Thomas et al., 1990) (see Teaching Guidelines box).


TEACHING GUIDELINES Postpartum Pain Relief After Cesarean Birth


Splint incision with a pillow when moving or coughing.

Use relaxation techniques such as music, breathing, and dim lights.

Apply a heating pad to the abdomen.


Walk as often as you can.

Do not eat or drink gas-forming foods, carbonated beverages, or whole milk.

Do not use straws for drinking fluids.

Take antiflatulence medication if prescribed.

Lie on your left side to expel gas.

Rock in a rocking chair.


Daily care includes perineal care, breast care, and routine hygienic care, including showering after the dressing has been removed (if showering is acceptable according to the women's cultural practices). The nurse assesses the woman's vital signs, incision, fundus, and lochia according to hospital policies, procedures, or protocols. Breath sounds, bowel sounds, circulatory status of lower extremities, and urinary and bowel elimination also are assessed. It is important to note maternal affect.

During the postpartum period the nurse can also provide care that meets the psychologic and teaching needs of mothers who have had cesarean births. The nurse can explain postpartum procedures to help the woman participate in her recovery from surgery. The nurse can help the woman plan care and visits from family and friends that will allow for adequate rest periods. Information on and assistance with infant care can facilitate adjustment to the mothering role. The woman is supported to breastfeed her baby by receiving individualized assistance to comfortably hold and position the baby at her breast. The partner can be included in infant teaching sessions and in explanations about the woman's recovery. The couple should also be encouraged to express their feelings about the birth experience. Some parents are angry, frustrated, or disappointed that a vaginal birth was not possible. Some women express feelings of low self-esteem or a negative self-image. Others express relief and gratitude that the baby is healthy and safely born. It may be helpful for them to have the nurse who was present during the birth visit and help fill in "gaps" about the experience. Other psychologic and lifestyle concerns that may occur after discharge include depression, feeling limited in activities, and changes in family interactions (Miovech et al., 1994; Ryding, Wijma, & Wijma,1998).

Discharge after cesarean birth is usually by the third postoperative day (Curtin & Kozak, 1998). The time is often determined by criteria established by the woman's insurance carrier or the federal government (e.g., diagnosisrelated groups).

The Newborn's and Mother's Health Protection Act of 1996 provides for a length of stay of up to 96 hours for cesarean births. These criteria may not coincide with the woman's physical or psychosocial readiness for discharge. Some states have added home care provisions for mothers who meet appropriate criteria for discharge and choose to leave sooner than the allowed length of stay. This policy recognizes that home care is less costly than hospital care and in most cases is more beneficial for recovery (Carpenter, 1998).

Eakes and Brown (1998) studied the expressed postdischarge needs of women who experienced planned and unplanned cesarean births. Findings revealed that the three predominant needs expressed by both groups of women were for rest and sleep; relief of pain and discomfort; and assistance with household chores, infant care and feeding, and self-care. Women who experienced planned cesarean births also expressed a need for help with depression, socialization, and family closeness, especially with regard to the limited amount of time they had to spend with their other children.

The nurse must provide discharge teaching to prepare women for self-care and newborn care in a limited time, while trying to ensure that the woman is comfortable and able to rest. The nurse should assess the woman's information needs and coordinate the health care team's efforts to meet them.

Discharge teaching and planning should include information about nutrition; measures to relieve pain and discomfort; exercise and specific activity restrictions; time management that includes periods of uninterrupted rest and sleep; hygiene, breast, and incisional care; timing for resumption of sexual activity and contraception; signs of complications (see Teaching Guidelines box and Self-Care box); and infant care. The nurse assesses the woman's need for continued support or counseling to facilitate her emotional recovery from the birth. The woman's family and friends should be educated regarding her needs during the recovery process, and their assistance should be coordinated before discharge. Referral to support groups or to community agencies may be indicated to further promote the recovery process. A postdischarge program of telephone follow-up and home visits can facilitate the woman's full recovery following cesarean birth.


Patient Instructions for Self-Care

Signs of Postoperative Complications After Discharge

Report the following signs to your health care provider:

Temperature exceeding 38° C

Painful urination

Lochia heavier than a normal period

Wound separation

Redness or oozing at the incision site

Severe abdominal pain


Vaginal birth after cesarean

Indications for primary cesarean birth, such as dystocia, breech presentation, or fetal distress, often are nonrecurring. Therefore a woman who has had a cesarean birth may subsequently become pregnant and not have any contraindications to labor and vaginal birth in that pregnancy. ACOG (1999) encourages a TOL and VBAC attempt in women who have had one previous cesarean birth by low transverse incision. Vaginal birth is relatively safe, but there is a risk for uterine rupture through a lower uterine segment scar. Increased reports of uterine rupture in the United States and Canada in the 1990s have raised concerns about the safety of VBAC. Recommendations for the use of VBAC are being reevaluated (ACOG, 1999; Cunningham et al., 2001). Labor and vaginal birth are not recommended if there are contraindications, such as a previous fundal classic cesarean scar or evidence of CPD.

According to Scott (1999), 60% to 88% of women can give birth vaginally after a TOL. Women are most often the primary decision makers with regard to choice of birth method. During the antepartal period, the women should be given information about VBAC and encouraged to choose it as an alternative to repeat cesarean birth, as long as no contraindications exist. VBAC support groups and prenatal classes can help prepare the woman psychologically for labor and vaginal birth. Women need to believe not only that their efforts during a TOL will be successful but also that they are fully capable of doing what is necessary to give birth vaginally (self-efficacy) (Dilks & Beal, 1997).

This labor should occur in a hospital facility that has the equipment and personnel available to begin the surgery within 30 minutes from the time a decision is made to perform cesarean birth. Ideally, the woman is admitted to the labor and birth unit at the onset of spontaneous labor. In the latent phase of labor, the nurse encourages her to engage in normal activities such as ambulation. In the active phase of labor, FHR and uterine activity usually are monitored electronically and intravenous access such as a heparin lock may be established. The physician should be immediately available during active labor.

There is no evidence that administering oxytocin to induce or augment labor or the use of epidural anesthesia is contraindicated, although caution and close monitoring of the laboring woman is urged if these are used (Cunningham et al., 2001).

Attention should be paid to the woman's psychologic, as well as physical, needs during the TOL. Anxiety can inhibit the release of oxytocin, thus delaying the progress of labor and possibly leading to a repeat cesarean birth. To alleviate such anxiety, the nurse can encourage the woman to use breathing and relaxation techniques and to change positions to promote labor progress. The woman's partner can be encouraged to provide comfort measures and emotional support (Fawcett, Tulman, & Spedden, 1994). Collaboration among the woman in labor, the nurse, and other health care providers often results in a successful VBAC. If a TOL does not proceed to vaginal birth, the woman will need support and encouragement to express her feelings about having another cesarean birth.



Evaluation of the effectiveness of nursing care for a woman experiencing dystocia is based on the expected outcomes.



Shoulder dystocia is an uncommon obstetric emergency that increases the risk for fetal/neonatal and maternal morbidity and mortality during the attempt to deliver the fetus vaginally. Fetopelvic disproportion related to excessive fetal size (macrosomia) or maternal pelvic abnormalities may be a cause of shoulder dystocia (Hall, 1997; Wiznitzer, 1995). The fetus/newborn is more likely to experience birth injuries related to asphyxia, brachial plexus damage, and fracture, especially of the humerus or clavicle. The mother's primary risk stems from excessive blood loss as a result of uterine atony or rupture, lacerations, extension of the episiotomy, or endometritis. It is estimated that 0.23% to 2.09% of all vaginal births are complicated by shoulder dystocia (Bruner et al., 1998; Naef& Martin, 1995).



Many maneuvers such as suprapubic pressure and maternal position changes have been suggested and tried to free the anterior shoulder, although no one particular maneuver has been found to be most effective (Naef & Morrison, 1994). Suprapubic pressure can be applied to the anterior shoulder using the Mazzanti or Rubin technique (Fig. 14) in an attempt to push the shoulder under the symphysis pubis (Naef & Morrison, 1994). Having the woman move to a hands-and-knees position, a squatting position, or a lateral recumbent position has also been used to resolve cases of shoulder dystocia (Hall, 1997; Piper & McDonald, 1994).



Fig. 14 Application of suprapubic pressure. A, Mazzanti technique. Pressure is applied directly posteriorly and laterally above the symphysis pubis. B, Rubin technique. Pressure is applied obliquely posteriorly against the anterior shoulder.


In the McRoberts maneuver (Fig. 15), the woman's legs are flexed apart, with her knees on her abdomen (Piper & McDonald, 1994). This maneuver causes the sacrum to straighten and the symphysis pubis to rotate toward the mother's head; the angle of pelvic inclination is decreased, freeing the shoulder. The McRoberts maneuver is the preferred method when a woman is receiving epidural anesthesia. The Gaskin maneuver requires that the woman assume an all-fours position on her hands and knees (Bruner et al., 1998). It is proposed that the effects of a change in position along with the force of gravity and slight increase in pelvic diameters play a role in the maneuver's effectiveness. Fundal pressure is usually not advised as a method of relieving shoulder dystocia (Naef & Morrison, 1994; Piper & McDonald, 1994).


Fig. 15. McRoberts maneuver. (Modified from Gabbe, S., Niebyl, J., & Simpson, J. [2002]. Obstetrics: Normal and problem pregnancies [4th ed.]. New York: Churchill Livingstone.


The nurse helps the woman to assume the position(s) that may facilitate birth of the shoulders, assists the primary health care provider with these maneuvers and techniques during birth, and documents the maneuvers. The nurse also provides encouragement and support to reduce anxiety and fear.

Newborn assessment should include examination for fracture of the clavicle or humerus, brachial plexus injuries, and asphyxia (Hall, 1997). Maternal assessment should focus on early detection of hemorrhage.



Prolapse of the umbilical cord occurs when the cord lies below the presenting part of the fetus. Umbilical cord prolapse may be occult (hidden, not visible) at any time during labor whether or not the membranes are ruptured (Fig. 16, A and B). It is most common to see frank (visible) prolapse directly after rupture of membranes, when gravity washes the cord in front of the presenting part (Fig. 16, C and D). Contributing factors include a long cord (longer than 100 cm), malpresentation (breech), transverse lie, or unengaged presenting part.



Fig. 16 Prolapse of umbilical cord. Note pressure of presenting part on umbilical cord, which endangers fetal circulation. A, Occult (hidden) prolapse of cord. B, Complete prolapse of cord. Note that membranes are intact. C, Cord presenting in front of the fetal head may be seen in vagina. D, Frank breech presentation with prolapsed cord


If the presenting part does not fit snugly into the lower uterine segment (e.g., as in polyhydramnios), when the membranes rupture, a sudden gush of amniotic fluid may cause the cord to be displaced downward. Similarly, the cord may prolapse during amniotomy if the presenting part is high. A small fetus may not fit snugly into the lower uterine segment; as a result, cord prolapse is more likely to occur.



Prompt recognition of a prolapsed umbilical cord is important because fetal hypoxia resulting from prolonged cord compression (i.e., occlusion of blood flow to and from the fetus for more than 5 minutes) usually results in central nervous system damage or death of the fetus. Pressure on the cord may be relieved by the examiner putting a sterile gloved hand into the vagina and holding the presenting part off of the umbilical cord (Fig. 17, A and B). The woman is assisted into a position such as a modified Sims (Fig. 17, C), Trendelenburg, or knee-chest (Fig. 17, D) position, in which gravity keeps the pressure of the presenting part off the cord. If the cervix is fully dilated, a forceps- or vacuum-assisted birth can be performed for the fetus in a cephalic presentation; otherwise a cesarean birth is likely to be performed. Nonreassuring fetal status, inadequate uterine relaxation, and bleeding can also occur as a result of a prolapsed umbilical cord. Indications for immediate interventions are presented in the Emergency box. Ongoing assessment of the woman and her fetus is critical to determine the effectiveness of each action taken. The woman and her family are often aware of the seriousness of the situation; therefore the nurse must provide support by giving explanations for the interventions being implemented and their effect on the status of the fetus.



Fig. 17 Arrows indicate direction of pressure against presenting part to relieve compression of prolapsed umbilical cord. Pressure exerted by examiner's fingers in A, vertex presentation, and B, breech presentation. C, Gravity relieves pressure when woman is in modified Sims position with hips elevated as high as possible with pillows. D, Knee-chest position.


EMERGENCY Prolapsed Cord


Fetal bradycardia with variable deceleration during uterine contraction.

Woman reports feeling the cord after membranes rupture.

Cord is seen or felt in or protruding from the vagina.


Call for assistance.

Notify primary health care provider immediately.

Glove the examining hand quickly and insert two fingers into the vagina to the cervix. With one finger on either side of the cord or both fingers to one side, exert upward pressure against the presenting part to relieve compression of the cord (Fig. 16, A and 6). Place a rolled towel under the woman's right or left hip.

Place woman into the extreme Trendelenburg or a modified Sims position (Fig. 16, C), or a knee-chest position (Fig. 16, D).

If cord is protruding from vagina, wrap loosely in a sterile towel saturated with warm sterile normal saline solution.

Administer oxygen to the woman by mask at 8 to 10 L/min until birth is accomplished.

Start IV fluids or increase existing drip rate.

Continue to monitor FHR by internal fetal scalp electrode, if possible.

Explain to woman and support person what is happening and the way it is being managed.

Prepare for immediate vaginal delivery if cervix is fully dilated or cesarean birth if it is not



Etiologic factors and clinical manifestations

Rupture of the uterus is a rare but very serious obstetric injury that occurs in 1 in 1500 to 2000 births. The most frequent causes of uterine rupture during pregnancy are separation of the scar of a previous classic cesarean birth, uterine trauma (e.g., accidents, surgery), and a congenital uterine anomaly. During labor and birth, uterine rupture may be caused by intense spontaneous uterine contractions, labor stimulation (e.g., oxytocin, prostaglandin), an overdistended uterus (e.g., multifetal gestation), malpresentation, external or internal version, or a difficult forceps-assisted birth. It occurs more commonly in multigravidas than in primigravidas (Varney, 1997).

A uterine rupture is classified as either complete or incomplete. A complete rupture extends through the entire uterine wall into the peritoneal cavity or broad ligament. An incomplete rupture extends into the peritoneum but not into the peritoneal cavity or broad ligament. Bleeding is usually internal. An incomplete rupture may also be a partial separation at an old cesarean scar and may go unnoticed unless the woman undergoes a subsequent cesarean  birth or other uterine surgery.

Signs and symptoms vary with the extent of the rupture and may be silent or dramatic. In an incomplete rupture, pain may not be present. The fetus may or may not have late decelerations, decreased variability, an increased or decreased heart rate, or other nonreassuring signs. The woman may experience vomiting, faintness, increased abdominal tenderness, hypotonic uterine contractions, and lack of progress. Eventually, bleeding and the effects of blood loss will be noted. Fetal heart tones may be lost. In a complete rupture the woman may complain of sudden, sharp, shooting abdominal pain and may state that "something gave way." If she is in labor, her contractions will cease and pain is relieved. She may exhibit signs of hypovolemic shock caused by hemorrhage (i.e., hypotension; tachypnea; pallor; and cool, clammy skin). If the placenta separates, the FHR will be absent. Fetal parts may be palpable through the abdomen. The nurse should suspect pulmonary embolism if the woman complains of chest pain (Varney, 1997).



Prevention is the best treatment. Women who have had a previous classic cesarean birth are advised not to attempt vaginal birth in subsequent pregnancies. Women at risk for uterine rupture are assessed closely during labor. Women whose labor is induced with oxytocin or prostaglandin (especially if their previous birth was cesarean) are monitored for signs of uterine hyperstimulation, because this can precipitate uterine rupture. If hyperstimulation occurs, the oxytocin infusion is discontinued or decreased and a tocolytic medication may be given to decrease the intensity of the uterine contractions. After giving birth, women are assessed for excessive bleeding, especially if the fundus is firm and there are signs of hemorrhagic shock.

If rupture occurs, the type of medical management depends on the severity. A small rupture may be managed with a laparotomy and birth of the infant, repair of the laceration, and blood transfusions, if needed. For a complete rupture, hysterectomy and blood replacement is the usual treatment.

The nurse's role may include starting intravenous fluids, transfusing blood products, administering oxygen, and assisting with the preparation for immediate surgery. Supporting the woman's family and providing information about the treatment are important during this emergency (Varney, 1997). The fetal mortality rate with rupture and expulsion into the peritoneal cavity is high (50% to 75%), and the maternal mortality rate may be high if the woman is not treated immediately (Cunningham et al., 2001). Providing information about spiritual support services or suggesting that the family contact their own support system may be warranted.



Amniotic fluid embolism (AFE) occurs when amniotic fluid containing particles of debris (e.g., vernix, hair, skin cells, meconium) enters the maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse. This can occur because fluid can enter the maternal circulation any time there is an opening in the amniotic sac or maternal uterine veins, accompanied by enough intrauterine pressure to force the amniotic fluid into the veins (e.g., if the placenta separates or if there are rapid or strong contractions that cause the uterus to lacerate or rupture). Although uncommon, this complication is estimated to be the cause of 10% of maternal deaths in the United States. The fetal mortality rate is estimated to be as high as 50% (Martin, 1996; Martin & Leaton, 2001).

Amniotic fluid is more damaging if it contains meconium and other particulate matter such as mucus, fat globules, lanugo, bacterial products, or debris from a dead fetus because emboli can then form more readily. Maternal death occurs most often when thick meconium is present in the amniotic fluid because this clogs the pulmonary veins more completely than other debris. Even if death does not occur immediately, serious coagulation problems such as disseminated intravascular coagulopathy usually occur.

Maternal factors, including multiparity, tumultuous labor, abruptio placentae, and oxytocin induction of labor, and fetal problems, including macrosomia, death, and meconium passage, have been associated with an increased risk for the development of AFE (Cunningham et al., 2001; Martin, 1996).



The immediate interventions for AFE are summarized in the Emergency box. Such medical management must be instituted immediately. Cardiopulmonary resuscitation is often necessary. The woman is usually placed on mechanical ventilation, blood replacement is initiated, and coagulation defects are treated. Although the incidence of possible complications is small, their immediate recognition followed by prompt initiation of treatment is important.

The nurse's immediate responsibility is to assist with the resuscitation efforts. If the woman survives, she is usually moved to a critical care unit, where hemodynamic monitoring and blood replacement and coagulopathy treatment are implemented.

Support of the woman's partner and family is needed; they will be anxious and distressed. Brief explanations of what is happening are important during the emergency and can be reinforced after the immediate crisis is over. If the woman dies, emotional support and involvement of the perinatal loss support team or other resource for grief counseling are needed. Referral to grief and loss support groups would be appropriate (see Resources at end of Chapter 28). The nursing staff may also need help in coping with their feelings and emotions that result from a maternal death.

EMERGENCY Amniotic Fluid Embolism


Respiratory Distress

• Restlessness

• Dyspnea

• Cyanosis

• Pulmonary edema

• Respiratory arrest

Circulatory Collapse

• Hypotension

• Tachycardia

• Shock

• Cardiac arrest


• Coagulation failure: bleeding from incisions, venipuncture sites, trauma (lacerations); petechiae, ecchymoses, purpura

• Uterine atony



• Administer oxygen by face mask (8-10 L/min) or resuscitation bag delivering 100% oxygen

• Prepare for intubation and mechanical ventilation

• Initiate or assist with cardiopulmonary resuscitation. Tilt pregnant woman 30 degrees to side to displace uterus

Maintain Cardiac Output and Replace Fluid Losses

• Position woman on her side

• Administer IV fluids

• Administer blood: packed cells, fresh frozen plasma

• Insert indwelling catheter, and measure hourly urine output

Correct coagulation failure

Monitor fetal and maternal status

Prepare for emergency birth once woman's condition is stabilized

Provide emotional support to woman, her partner, and family