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15 Complications of Labor and Birth 279 Complications of 15 Labor and Birth CHAPTER CHAPTER http://evolve.elsevier.com/Leifer/maternity Objectives augmentation of labor (a˘wg-me˘n-TA¯ -shu˘n, p. •••) Bishop score (p. •••) On completion and mastery of Chapter 15, the student will be able to do cephalopelvic disproportion (CPD) (se˘f-a˘-lo¯ -PE˘L- v i˘c the following: di˘s-pro¯ -PO˘ R-shu˘n, p. •••) 1. Defi ne key terms listed. cesarean birth (se˘-ZA¯ R-e¯-a˘n, p. •••) 2. Discuss four factors associated with preterm labor. chorioamnionitis (ko¯ -re¯-o¯-a˘m-ne¯-o¯ -NI¯-ti˘s, p. •••) 3. Describe two major nursing assessments of a woman dysfunctional labor (p. •••) ˘ ¯ in preterm labor. dystocia (dis-TO-se¯-a˘, p. •••) episiotomy (e˘-pe¯ z-e¯-O˘ T- o¯ -me¯, p. •••) 4. Explain why tocolytic agents are used in preterm labor. external version (p. •••) 5. Interpret the term premature rupture of membranes. fern test (p. •••) 6. Identify two complications of premature rupture of forceps (p. •••) membranes. hydramnios (hi¯-DRA˘ M-ne¯-o˘s, p. •••) 7. Differentiate between hypotonic and hypertonic uterine hypertonic uterine dysfunction (hi¯-pe˘r-TO˘ N-i˘k U¯ -te˘r-i˘n, dysfunction. p. •••) 8. Name and describe the three different types of breech hypotonic uterine dysfunction (hi¯-po¯-TO˘ N-i˘k, p. •••) presentation. induction of labor (p. •••) ¯ 9. List two potential complications of a breech birth. multifetal pregnancy (mu˘l-te¯-FE-ta˘l, p. •••) nitrazine paper test (NI¯-tra˘-ze¯n, p. •••) 10. Explain the term cephalopelvic disproportion (CPD), and oligohydramnios (p. •••) discuss the nursing management of CPD. oxytocin (o˘ks-e¯-TO¯ -si˘n, p. •••) 11. Defi ne and identify three common methods used to precipitate labor (pre¯-SI˘P-i˘-ta¯t, p. •••) induce labor. preterm labor (p. •••) 12. Explain why an episiotomy is performed, and name two prolapsed umbilical cord (PRO¯ -la˘pst u˘m-BI˘L- i˘-ka˘l, p. •••) basic types of episiotomies. prostaglandin (PGE2) gel (p. •••) 13. Describe three types of lacerations that can occur dur- tocolytic agents (to¯-ko¯ -LI˘T- i˘k, p. •••) ing the birth process. trial of labor (p. •••) 14. List two indications for using forceps to deliver the fetus. uterine rupture (p. •••) vaginal birth after cesarean (VBAC) (p. •••) 15. Describe vacuum extraction. 16. Defi ne precipitate labor, and describe two nursing ac- tions that should be taken to safeguard the baby. 17. Review the most common cause of rupture of the abor and birth usually progress with few prob- uterus during labor. Llems. However, when complications occur during 18. Describe umbilical cord prolapse, and state two associ- labor, they can have devastating effects on the ated potential complications. maternal-fetal outcome. Health care providers must 19. List three potential complications of multifetal preg- quickly and accurately identify the nature of the prob- nancy. lems and intervene to reduce or limit detrimental ef- 20. Discuss fi ve indications for a cesarean birth. fects on the mother and newborn. This chapter dis- 21. Describe the preoperative and postoperative care of a cusses high-risk intrapartum care. Nursing care is woman who is undergoing a cesarean birth. incorporated throughout the chapter. 22. Discuss the rationale for vaginal birth after a prior cesar- ean birth. PRETERM LABOR Key Terms Preterm labor is defi ned as the onset of labor between Be sure to check out the bonus material on the Companion CD-ROM, 20 and 37 weeks’ gestation. It occurs in approximately including selected audio pronunciations. 8% of pregnancies and accounts for most perinatal amnioinfusion (a˘m-ne¯-o¯-i˘n-FU¯ -zha˘n, p. •••) deaths not resulting from congenital anomalies. Pre- amniotomy (a˘m-ne¯-O˘ T- o˘-me¯, p. •••) term labor and premature rupture of membranes are 277 Leifer 978-1-4160-4870-1/0021 CCh15_277-298_X4870.inddh15_277-298_X4870.indd 227777 77/18/07/18/07 99:41:25:41:25 AAMM 278 UNIT SEVEN COMPLICATIONS OF CHILDBEARING the two most common factors that lead to preterm The length of the cervix can be measured by transvagi- birth. Preterm birth has great signifi cance for society nal ultrasound. because of the high rate of perinatal deaths and the excessive fi nancial cost of caring for the preterm new- Signs and Symptoms borns. One of the Healthy People 2010 (Centers for Dis- Clinical manifestations of preterm labor are more sub- ease Control and Prevention, 2000) goals is for 90% of tle than for term labor. Health care providers and preg- all pregnant women to have prenatal care starting in nant women need to know the warning signs of pre- the fi rst trimester. Early prenatal care makes it possi- term labor. The health care provider should be notifi ed ble for the woman to reduce or eliminate some risk of the following signs or symptoms: factors that contribute to preterm labor (Fast Focus • Uterine cramping (menstrual-like cramps) 15-1). • Abdominal cramping (with or without nausea, vomiting, or diarrhea) • Any vaginal bleeding • Change in vaginal discharge Fast Focus 15-1 • Vaginal or pelvic pressure • Low back pain Risk Factors for Preterm Labor • Thigh pain (intermittent or persistent) • History of preterm delivery • Multifetal pregnancy Assessment and Management • Bacterial vaginosis Early prenatal care and education about prevention • Short cervix and the warning signs of preterm labor are extremely • Fetal abnormality important to prevent preterm birth. The nurse should • Hydramnios review the signs and symptoms that place a woman at • Substance abuse risk for preterm labor and emphasize the importance • Trauma or surgery during pregnancy of reporting the signs for prompt care in order to delay • Periodontal dental disease • Fibronectin in vaginal secretions between 22 and 37 the newborn’s birth until the fetal lungs are mature weeks’ gestation enough for extrauterine life. Open communication be- • Alkaline phosphatase level greater than 90th percentile tween the woman, nurse, and other health team mem- • Alpha-fetoprotein level greater than 90th percentile bers is essential for collaborative care and successful • Increased estriol level in urine after 32 weeks’ gestation prevention of preterm births. Once the woman has been identifi ed as at high risk for preterm labor, the use of various strategies and more intense surveillance al- The criteria for diagnosing preterm labor include: lows earlier identifi cation and intervention for preterm • Gestation less than 36 weeks labor. • Documented uterine contractions every 5 to 10 When amniotic membrane integrity is lost, a protein minutes lasting for at least 30 seconds and per- in the amniotic fl uid called fi bronectin will be found in sisting for more than 1 hour vaginal secretions. A vaginal swab for fetal fi bronectin • Cervical dilation more than 2.5 cm and 75% can help the physician decide which women should be effaced treated most aggressively to stop preterm labor (Gabbe, Niebyl, & Simpson, 2007). Associated Factors Infection is associated with preterm births. Identifi - The exact cause of preterm labor is unclear; however, cation and eradication of offending microorganisms several risk factors are known. Because epidemiologic that cause infl ammation in the lower reproductive tract data have shown some risk factors to be avoidable, lessen the infl ammatory response and provide a health- there are some promising avenues for both prevention ier cervix, thereby decreasing the incidence of preterm and treatment. Increased risk factors include poor pre- labor. Antibiotics may be prescribed prophylactically natal care; infections, including periodontal (dental) for women at risk for preterm labor, with premature infections; nutritional status; and sociodemographics rupture of the membranes, or with group B streptococ- (socioeconomic status, race, and lifestyle). Preterm la- cal cervical cultures (Morantz, 2004). bor, followed by preterm birth, has been associated The physician may order uterine activity monitor- with maternal anemia; urinary tract infection; cigarette ing at home for women at risk for preterm labor. The smoking; and use of alcohol, cocaine, and other sub- monitor assesses contractions only; it does not assess stances, all of which are potentially avoidable risk fac- fetal heart rate (see Chapter 19). In the delivery unit the tors. In addition, alterations in maternal vaginal fl ora pediatrician should be present to assist in assessment by pathogenic organisms (e.g., Chlamydia or Tricho- and resuscitation of the preterm newborn, and equip- monas organisms, bacterial vaginosis) are associated ment and a working incubator for transportation to the with preterm labor. The risk of spontaneous preterm neonatal intensive care unit (NICU) should also be birth increases as the length of the cervix decreases. available. Leifer 978-1-4160-4870-1/0021 CCh15_277-298_X4870.inddh15_277-298_X4870.indd 227878 77/18/07/18/07 99:41:25:41:25 AAMM CHAPTER 15 Complications of Labor and Birth 279 Stopping Preterm Labor. Once the woman is admitted Tocolytics should not be used in women who are to the hospital and the diagnosis of preterm labor is hemorrhaging, since vasodilation may increase bleed- made, management focuses on stopping the uterine ing. If signs of fetal distress are noted, tocolytics may activity (contractions) before the cervix dilates beyond 3 not be used if adequate survival therapy is available cm, or “the point of no return.” The initial measures to in the NICU. Tocolytics are usually not effective in stop preterm labor include identifying and treating any cervical dilation of 5 cm or more. After cessation of infection, restricting activity, ensuring hydration, and contraction, glyceryl trinitrate in the form of skin using tocolytic drugs (Table 15-1). The woman is placed patches may be prescribed. Headache is a common on modifi ed bed rest with bathroom privileges and is side effect. encouraged to maintain a lateral position. Assessment The woman should be asked to report any vaginal of uterine activity by palpation provides valuable infor- discharge (color, consistency, and odor).
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