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 assistant professor N.Petrenko, MD, PhD

LEARNING OBJECTIVES

• 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.

 

KEY TERMS AND DEFINITIONS

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

abdomen

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 AND BIRTH

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).

 

PRETERM BIRTH VERSUS LOW BIRTH WEIGHT

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).

 

PREDICTING PRETERM LABOR AND BIRTH

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 DEMOGRAPHIC RISKS • Nonwhite race • Age (<17, >35) • Low socioeconomic status • Unmarried • Less than high school education BIOPHYSICAL RISKS • 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 BEHAVIORAL-PSYCHOSOCIAL RISKS • 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 MATERNAL BEHAVIORS Smoking Substance use (alcohol or illegal drugs) Poor nutrition Work/fatigue Short interpregnancy interval Sexual activity MATERNAL CHARACTERISTICS Young or old age Previous preterm birth Short stature Short cervix Uterine anomalies Diethylstilbestrol exposure Prematurely dilated cervix Low prepregnancy weight African-American Unmarried Low socioeconomic status Victim of domestic violence OTHER FACTORS Inadequate support systems Stress Uterine irritability Multiple gestation Late or no prenatal care Preterm premature rupture of membranes Anemia Infection 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.

CARE MANAGEMENT

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

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 ACTIVITY • Uterine contractions more frequent than every 10 minutes persisting for 1 hour or more • Uterine contractions may be painful or painless DISCOMFORT • 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 VAGINAL DISCHARGE • 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 MATERNAL EFFECTS (PHYSICAL) • 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 MATERNAL EFFECTS (PSYCHOSOCIAL) • 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) EFFECTS ON SUPPORT SYSTEM • 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 MATERNAL Severe pregnancy-induced hypertension or eclampsia Active vaginal bleeding Intrauterine infection Cardiac disease Medical or obstetric condition that contraindicates continuation of pregnancy FETAL Estimated gestational age over 37 weeks Dilation over 4 cm Fetal demise Lethal fetal anomaly Chorioamnionitis 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
MEDICATION/ ACTION	DOSAGE AND ROUTE	ADVERSE REACTIONS	NURSING CONSIDERATIONS
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 maintenance • 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; Adalat) 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 Hypotension Dizziness, headache. nervousness Peripheral edema Fatigue Nausea Facial flushing	Do not use with magnesium sulfate Assess woman and fetus according to agency protocol being alert for adverse reactions Do not use sublingual route
Indomethacin* 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 ACTION 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). INDICATION To prevent or reduce the severity of respiratory distress syndrome in preterm infants between 24 and 34 weeks of gestation DOSAGE AND ROUTE 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. ADVERSE REACTIONS Possible maternal infection, pulmonary edema (if given with /3-adrenergic medications), may worsen maternal condition (diabetes, hypertension) NURSING CONSIDERATIONS 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

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.

PRETERM PREMATURE RUPTURE OF MEMBRANES

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.

 

CARE MANAGEMENT

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).

 POSTTERM PREGNANCY, LABOR, AND BIRTH

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).

 

MATEMAL AND FETAL RISKS

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).

 

CARE MANAGEMENT

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.

CARE MANAGEMENT

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

-pain

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

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
	Score
	0	1	2	3
Dilation (cm)	0	1-2	3-4	>5
Effacement (%)	0-30	40-50	60-70	>80
Station (cm)	-3	-2	-1	+ 1, +2
Cervical consistency	Firm	Medium	Soft
Cervix positior	Posterior	Midposterior	Anterior

 

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) ACTION PGE, ripens the cervix, making it softer and causing it to begin to dilate and efface; stimulates uterine contractions. INDICATIONS 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). DOSAGE 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) ADVERSE REACTIONS 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. NURSING CONSIDERATIONS • 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) ACTION PGE2 ripens the cervix, making it softer and causing it to begin to dilate and efface; stimulates uterine contractions. INDICATIONS 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) DOSAGE 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. ADVERSE REACTIONS 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. NURSING CONSIDERATIONS • 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.