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. (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. •••) (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 . multifetal (mu˘l-te¯-FE-ta˘l, p. •••) nitrazine paper test (NI¯-tra˘-ze¯n, p. •••) 10. Explain the term cephalopelvic disproportion (CPD), and (p. •••) discuss the nursing management of CPD. (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 (PRO¯ -la˘pst u˘m-BI˘L- i˘-ka˘l, p. •••)

basic types of . (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 . (p. •••) vaginal birth after cesarean (VBAC) (p. •••) 15. Describe . 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 , 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’ . It occurs in approximately including selected audio pronunciations. 8% of and accounts for most perinatal (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

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the two most common factors that lead to preterm The length of the cervix can be measured by transvagi- 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 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 • 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.

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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 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). Baseline ma- mation. The nurse communicates with the woman to ternal vital signs are important and may provide clues help reduce her anxiety and concerns about fetal well- of infection. Tachycardia and elevation of temperature being and birth. Anxiety produces high levels of circu- can be early signs of amniotic fl uid infection. lating catecholamines, which may induce further uter- Fetal surveillance includes external fetal monitor- ine activity. Explaining the planned care and procedures ing; fetal tachycardia of more than 160 beats/min may can reduce the patient’s fear of the unknown. Ritodrine indicate infection or distress. Fetal movement and bio- and other tocolytics can have an effect on carbohydrate physical profi le assessment with the metabolism and are used with caution in the diabetic (NST) provide information about fetal well-being. Spe- patient (Pitkin, Peattie, & Magowan, 2003). cial fetal assessment tests can be performed, such as

Table 15-1 Drugs Used to Stop Preterm Labor (Tocolytics)

TOCOLYTIC DRUG ADVERSE EFFECTS COMMENTS Ritodrine (Yutopar) Cardiovascular: maternal and fetal tachycardia Side effects dose related and more promi- (␤-adrenergic agonist) Pulmonary: shortness of breath, chest pain, pulmonary nent during increases in the infusion rate , tachypnea than during maintenance therapy Gastrointestinal: nausea, vomiting, diarrhea, ECG clearance suggested; hypertension Central nervous system: tremors, jitteriness, restless- and uncontrolled diabetes mellitus are ness, apprehension contraindications Metabolic alterations: hyperglycemia, hypokalemia, hypocalcemia Magnesium sulfate Depression of deep tendon refl exes, respira- Adverse effects dose related, occurring at tory depression, cardiac arrest (usually at serum higher serum levels magnesium levels Ͼ12 mg/dl) Less serious side effects: lethargy, weakness, visual blurring, headache, sensation of heat, nausea, vomiting, constipation, oliguria Fetal-neonatal effects: reduced heart rate variability, Indomethacin Epigastric pain, gastrointestinal bleeding; increased (prostaglandin risk for bleeding; dizziness. synthesis inhibitor) Fetal effects: may have constriction of ductus arterio- sus and decreased urinary output; decreased urinary output is associated with oligohydramnios, which may result in cord compression Respiratory distress syndrome Nifedipine (Procardia) Maternal fl ushing, transient tachycardia, hypotension; (calcium channel use with magnesium sulfate can cause serious blocker) hypotension and low calcium levels Corticosteroids Increased sugar Given to accelerate production of surfactant, increase fetal lung maturity, and prevent neonatal intracranial hemorrhage Betamethasone, Monitor mother and newborn closely: mother for Given to mother 24-48 hr before birth of dexamethasone pulmonary edema and hyperglycemia, and newborn preterm newborn (Ͻ34 wk gestation) for heart rate changes because it can hasten lung maturity Terbutaline (Brethine) Tachycardia; monitor vital signs (␤-adrenergic agonist) Shortness of breath; monitor insertion site for infection

Data from London, M., Ladewig, P., Ball, J., & Bindler., R. (2007). Maternal child nursing (2nd ed.). Upper Saddle River, NJ: Prentice Hall; Oats, J., & Abraham, S. (2005). Llewellyn-Jones fundamentals of and gynaecology (8th ed). St. Louis: Mosby; and Pitkin, J., Peattie, A., & Magowan, B. (2003). Obstetrics and gynaecology: an illustrated colour text. London: Churchill Livingstone. ECG, Electrocardiogram.

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measuring lecithin/sphingomyelin (L/S) ratio to de- may indicate profound hemodynamic changes includ- termine fetal lung maturity. ing decreased ventricular fi lling time; decreased car- Resting in the lateral position increases blood fl ow diac output and myocardial infarction may occur if the to the uterus and may decrease uterine activity. Strict drug is not discontinued. A pulse oximeter and arterial bed rest may have some adverse side effects, which in- blood gas results may be used to determine maternal clude muscle atrophy, bone loss, changes in cardiac oxygenation and acid-base balance. The woman may output, decreased gastric motility, and gastric refl ux. be placed in Fowler’s position and given oxygen as In addition, bed rest may result in depression and anx- needed. Tocolytic therapy is discontinued if the woman iety in the woman. has chest pain or shortness of breath. When corticoste- Hydration is encouraged, and intravenous fl uids are roids are given, the nurse must observe for fl uid reten- often administered to increase vascular volume and pre- tion and pulmonary edema. Indomethacin can con- vent dehydration. The pituitary gland responds to dehy- strict the ductus arteriosus in the fetus and reduces dration by secreting antidiuretic hormone and oxytocin. amniotic fl uid by reducing fetal kidney function. Indo- Therefore preventing dehydration will prevent oxytocin methacin also affects platelets, and therefore mother from being released. A baseline admission complete and newborn must be observed closely for bleeding. blood count is useful for determining if there has been a Side effects of magnesium sulfate include a feeling of decrease in the hemoglobin and hematocrit levels. warmth, headache, nausea, and lethargy. Nifedipine Use of tocolytic agents is an additional measure un- and magnesium sulfate cannot be used together, since dertaken to stop uterine activity. The goal of tocolytic low maternal calcium levels may occur. Progesterone therapy is to delay delivery until steroids can hasten therapy is under study for use as a tocolytic (London, lung maturity of the fetus. Several drugs can be used, Ladewig, Ball, & Bindler, 2007). but none is without side effects. The nurse must know the adverse effects of the drug given and monitor the Home Care Management woman for their possible appearance. ␤-Adrenergic- If the woman meets appropriate criteria, the primary agonist drugs such as terbutaline or ritodrine are often health care provider may consider home care (see used as tocolytics. Indomethacin (Indocin) should be Chapter 19). There is evidence that using the home available to reverse adverse effects. Magnesium sulfate uterine activity monitor (HUAM) is effective in de- is also an effective tocolytic. Calcium gluconate should creasing preterm births in a select group of women. be available to aid in reversing any toxic effects. Detecting contractions or contraction frequency before Chapter 14 discusses the nurse’s role regarding as- cervical changes occur makes HUAM worthwhile. sessment for magnesium sulfate toxicity. Intervention for magnesium sulfate administration is the same as when given to prevent seizures in gestational hyper- PREMATURE RUPTURE OF MEMBRANES tension. Promotion of Fetal Lung Maturity. Promotion of fetal Spontaneous rupture of the more than 1 lung maturity is a goal in management because respi- hour before onset of true labor is referred to as prema- ratory distress syndrome (RDS) is a common problem ture rupture of membranes (PROM). Rupture of the in preterm newborns. Respiratory distress can be re- membranes before 37 weeks’ gestation is known as duced if steroids, such as betamethasone or dexameth- preterm premature rupture of the membranes asone, are given to the mother at least 24 to 48 hours (PPROM). The exact cause is unknown, but there are before the birth of a newborn who is less than 34 several risk factors. weeks’ gestation. After birth, preterm newborns are Infection for both the mother and the fetus is the commonly treated prophylactically with surfactant major risk; when membranes are ruptured, microor- therapy to reduce the risk of RDS. ganisms from the vagina can ascend into the amniotic sac. Compression of the umbilical cord can occur as a Nursing Care Related to Pharmacologic Therapy result of the loss of amniotic fl uid. Prolapse of the cord All tocolytic therapies have maternal risks; therefore can also occur, which results in fetal distress. Because continuous assessment for effects of the drugs is indi- amniotic fl uid is slightly alkaline, confi rmation that the cated during administration. Intravenous tocolytics vaginal fl uid is amniotic fl uid can be obtained by a ni- are given according to the institution’s protocol. Accu- trazine paper test, which that will turn blue-green on rate intake and output, bilateral breath sounds, changes contact with amniotic fl uid (Skill 15-1). Examination of in vital signs, and mental status are closely monitored the fl uid under a microscope (fern test) will also show to identify early signs of fl uid overload and pulmonary a ferning pattern as the fl uid dries. edema. If the woman is receiving ␤-adrenergic-agonist drugs such as Ritodrine or Terbutaline, a heart rate of Management 120 beats/min or greater, or a decrease in blood pres- Treatment depends on the duration of gestation and sure to less than 90/40 mm Hg, should be immediately whether evidence of infection or fetal or maternal reported to the health care provider. These fi ndings compromise is present. For many women near term,

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PROM signifi es the imminent onset of true labor. If Infection of the amniotic sac, called chorioamnion- pregnancy is at or near term and the cervix is soft and itis, may be caused by prematurely ruptured mem- with some dilation and effacement, then augmenta- branes because the barrier to the uterine cavity is bro- tion of labor may be started a few hours after rupture. ken. The risk of infection increases if the membranes If the woman is not at term, the risk of infection or have been ruptured for more than 18 hours. preterm birth is weighed against the risks of an in- Management will likely consist of bed rest with duction by oxytocin or a cesarean birth (Nursing Care bathroom privileges and observation for infection, Plan 15-1). NST, and daily assessment for fetal compromise. Anti-

Skill 15-1 Testing for the Presence of (Nitrazine Paper Test) • Explain purpose to woman. • A yellow to yellow-green color of the strip of paper • Wash hands; apply clean gloves. indicates fl uid is acidic and is most likely urine. • Place piece of nitrazine paper into fl uid from va- • Document and report results, offer and provide gina. pericare, remove gloves, and wash hands. • A blue-green or deep blue color of the nitrazine • Document the presence of bloody show, which may paper indicates fl uid is alkaline and most likely alter accuracy of results. amniotic fl uid.

NURSING CARE PLAN 15-1 Preterm Premature Rupture of the Membranes (PPROM)

Scenario: A woman who is para 0, gravida 1 is admitted to the antepartum unit with possible ruptured membranes. She is at 30 weeks’ gestation and has not had any uterine contractions.

SELECTED NURSING DIAGNOSIS Risk for Infection related to effects of PPROM Expected Outcomes Nursing Interventions Rationales No infection will be present, Determine and record time of Provides baseline data. The length of time as evidenced by: PPROM, how much vaginal between rupture of the amniotic membranes • FHR 110-160 beats/min fl uid there was, the color and and delivery correlates with risk for infection. • Maternal temperature odor of the fl uid, and expected Color and foul odor can indicate presence 36.1°-37.2° C (97°-99° F) date of delivery (EDD). of infection. EDD is important in helping • Maternal white blood to determine whether rupture has occurred count Ͻ12,000/mm3 prematurely. • Absence of foul-smelling Assist with sterile speculum ex- Confi rms rupture by presence of pooling amni- vaginal discharge amination. otic fl uid, nitrazine paper turning blue, and • C-reactive protein fern pattern on slide when viewed under a negative microscope. Also allows for visual inspection of cervix to determine degree of dilation. Determine FHR and uterine con- Identifi es nonreassuring FHR patterns so that traction pattern with electronic early intervention can occur. Presence of uter- fetal monitoring. ine contractions can be a positive sign if fetus is Ն37 wk gestation. However, measures may need to be taken to end contractions if fetus is Ͻ37 wk gestation. In a term newborn, induc- tion of labor usually will be initiated at 12 hr after rupture if labor has not started. Assist with fetal assessment tests if Assesses fetal lung maturation and presence indicated. of infection. L/S ratio Ͼ2:1, prostaglandin positive, and lamellar body count Ͼ30,000 units/L are usually indicative of lung matu- rity. A Gram stain of amniotic fl uid can reveal presence of infectious microorganisms. Administer glucocorticoids as Aids in the maturation of the fetal lungs. ordered.

FHR, Fetal heart rate; L/S, lecithin/sphingomyelin. Continued

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NURSING CARE PLAN 15-1—cont’d Preterm Premature Rupture of the Membranes (PPROM)—cont’d Expected Outcomes Nursing Interventions Rationales Assess temperature per protocol Foul-smelling vaginal discharge and maternal and vaginal discharge at least fever are indicative of infection and must every 4 hr. be reported immediately to the health care provider. Review laboratory results. Elevation of leukocytes, presence of C-reactive protein, and a low amniotic fl uid glucose level are indicative of infection. Teach patient to wipe perineum Proper pericare reduces the risk of infection. from front to back. Change linens and underpads Moisture is an excellent medium for growth of frequently to keep patient dry. microorganisms. Maintain on bed rest unless fetal Prevents cord prolapse. presenting part is fully engaged. Provide patient with diversional Eliminates boredom of prolonged bed rest. activities. Keep patient informed of fetal Alleviates anxiety. condition. Explain rationales for all treat- Information often increases compliance with ments. treatment regimen. Provide emotional support. Anxiety and fear are common reactions to the threat of giving birth to a premature newborn and to the risk for infection.

CRITICAL THINKING QUESTIONS

■ The health care provider tells you to prepare the ■ When caring for a woman with PROM, how can you woman for a vaginal examination to assess for rup- decrease the risk for infection? tured membranes. What should you have available during the examination?

Table 15-2 Management of Women with Premature Rupture of the Membranes (PROM)

WOMEN WITH PROM PRETERM FETUS TERM FETUS Bed rest Determination of PROM Induction of labor if spontaneous labor has not Hydration Assessment for prolapsed cord begun by approximately 12 hr after PROM Sedation Observation for infection Potential for cesarean birth Antibiotics, if needed Administration of corticosteroids, with or without Expectant management of maternal-fetal infection Reassurance delivery in 24-48 hr Increased chance of asphyxia and respiratory dis- Delivery when the has the best chance for tress in newborn after birth survival (i.e., avoid fetal distress) Have emergency resuscitation equipment available

biotics are given to reduce infection and steroids to • Having the woman remain on bed rest in a lat- hasten fetal lung development (Table 15-2). eral position (with bathroom privileges) The woman may remain in the hospital until birth; • Instructing the woman to document fetal activity however, if there is no sign of infection or fetal compro- (daily kick counts) and report fewer than 10 kicks mise, she may return home and self-monitor. Prepara- in a 12-hour period tion for nursing management includes: • Explaining activity restrictions • Documenting vital signs daily and reporting any • Explaining the need to abstain from sexual inter- temperature greater than 38° C (100.4° F) course and orgasm • Providing sterile equipment for vaginal exami- • Telling the woman to avoid breast stimulation, nations which can cause release of oxytocin and initiate • Reporting uterine contractions uterine contraction • Reporting any vaginal discharge or bleeding • Assessing psychosocial concerns

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DYSTOCIA Dystocia can be associated with problems such as maternal dehydration, exhaustion, increased risk of in- Dystocia, also known as dysfunctional labor, is a diffi - fection, and fetal distress. Change in maternal vital cult or abnormal labor. It primarily results from one of signs such as elevation of temperature or rise in pulse the following problems (Table 15-3): rate should be reported. Comfort measures should be Powers: abnormal uterine activity (ineffective uter- implemented by nursing personnel, and the woman ine contractions) and signifi cant other should be kept informed about Passageway: abnormal pelvic size or shape and the progress of labor. other conditions that interfere with descent of the presenting part (such as tumors or soft tissue re- POWERS sistance) Abnormal Uterine Contractions Passenger: abnormal fetal size or presentation (ex- Dysfunctional labor can result from abnormal uterine cessive size or less than optimum position) contractions that prevent normal progress of cervical Psyche: past experiences, culture, preparation, and dilation, effacement, and descent of the presenting support system part. It can be further described as being primary (hy- Dystocia is suspected when the rate of cervical dila- pertonic dysfunction) or secondary (hypotonic dys- tion or fetal descent is not progressing normally or function). uterine contractions are ineffective. A , with potential injury to the fetus, may result. Electronic Hypotonic Dysfunction fetal monitoring (EFM) is used to assess uterine con- Hypotonic uterine dysfunction (secondary uterine in- tractions and fetal well-being. Nursing assessment of ertia) occurs with abnormally slow progress after the the intensity, frequency, and duration of contractions is labor has been established (Table 15-4). The uterine important. contractions become weak and ineffi cient and may even stop. The contractions are fewer than two or three in a 10-minute period and usually are not strong Table 15-3 Causes of Dystocia (Dysfunctional Labor) enough to cause the cervix to dilate beyond 4 cm, and CAUSE EXAMPLES the fundus does not feel fi rm at the height (or acme) of the contraction. Consequently, labor fails to progress. Diffi culty with powers Uterine dysfunction or abnor- A prolonged labor can occur, which can increase the malities Diffi culty with passageway Pelvic size and shape, tumors risk of intrauterine infection, placing both the mother Diffi culty with passenger Fetal abnormality and newborn at risk. Excessive size Hypotonic contractions occur as a result of fetopel- Malpresentation vic disproportion, fetal malposition, overstretching of Malposition Psyche Maternal anxiety, fatigue the uterus caused by a large newborn, multifetal ges- tation, or excessive maternal anxiety. The woman

Table 15-4 Comparison of Hypotonic and Hypertonic Labor

WHEN OCCURS CONTRACTIONS IMPLICATIONS MANAGEMENT HYPOTONIC LABOR Active phase; may occur Infrequent; poor inten- Maternal: seldom painful; Rule out cephalopelvic disproportion; use in latent phase sity; low resting tone prolonged labor; PROM; intravenous oxytocin to stimulate contrac- between contractions risk of infection; anxiety tions; perform cesarean birth for abnor- Fetal: risk of subsequent mal fetal position or large newborn. sepsis Nursing interventions: assess contraction pattern; provide support; monitor vital signs; frequently assess fetal status; if considering cesarean birth, instruct mother about procedure HYPERTONIC LABOR Prolonged latent phase; Become more frequent; Maternal: exhaustion, Analgesia for rest; hydration; oxytocin is not may occur in active ineffective; painful; discouragement, fatigue, administered (discontinue intravenous phase uterus does not relax anxiety oxytocin if infusing) between contractions Fetal: possible distress Nursing interventions: assess uterine with decreased placental contraction pattern; provide rest (analge- perfusion sia); provide comfort measures; monitor maternal vital signs; frequently monitor fetal status Lateral position; oxygen by mask PROM, Premature rupture of membranes.

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with hypotonic contractions can become exhausted and dehydrated. Medical management includes rul- PASSENGER ing out cephalopelvic disproportion (CPD) by ultra- Cephalopelvic Disproportion sound. If CPD is not the problem, augmentation by Cephalopelvic disproportion (CPD) is a condition in oxytocin is often started. The use of epidural analge- which the presenting part of the fetus (usually the sia and other regional anesthesia may reduce the ef- head) is too large to pass through the woman’s pelvis. fectiveness of the woman’s voluntary pushing efforts. Because of the disproportion, it becomes physically Encouraging position changes and coaching can be impossible for the fetus to be delivered vaginally, and helpful. cesarean birth is necessary. CPD is suspected when the newborn’s head does not continue to descend even Hypertonic Uterine Dysfunction though the woman is having strong uterine contrac- Hypertonic uterine dysfunction refers to a labor with tions. Excessive fetal size may be associated with dia- uterine contractions of poor quality that are painful, betes mellitus, multiparity, and genetics (one or both out of proportion to their intensity, do not cause cer- parents of large size). A large newborn (macrosomia) vical dilation or effacement, and are usually uncoor- can cause diffi culty in birth of the shoulders (shoulder dinated and frequent (see Table 15-4). This is more dystocia). A modifi ed position can aid in delivery (Fig- common with a fi rst pregnancy or an anxious woman ure 15-1). Maternal complications that can occur are who has intense pain and lack of labor progression. exhaustion, hemorrhage, and infection. The latent period of labor is prolonged, which in- and anoxia are complications for the fetus. creases her exhaustion and anxiety. Often there is not adequate relaxation of muscle tone between contrac- Abnormal Fetal Presentation tions, which causes the woman to complain of con- A malpresentation refers to any presentation of the fe- stant cramps and results in ischemia or reduced blood tus other than the vertex presentation, in which the top fl ow to the fetus. of the head emerges fi rst. Malpresentation may pro- Management of hypertonic uterine dysfunction is long labor and make it more uncomfortable for the rest, which is achieved by analgesia to reduce pain woman. and encourage sleep. An intravenous infusion is fre- Breech Presentation. Breech presentations are often quently administered to maintain hydration and elec- associated with preterm birth, multiple gestation, con- trolyte balance. Often women awaken with normal genital anomalies, previa, and multiparity. contractions. Breech is the most common example of malpresenta- tion. It occurs in approximately 3% to 4% of all births. PASSAGEWAY: ABNORMAL PELVIS SIZE OR SHAPE Contractures of the pelvic diameters reduce the capac- ity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes. Pelvic con- tractures may be caused by congenital malformations, rickets, maternal malnutrition, tumors, and previous pelvic fractures. Inlet contractures occur when the diagonal conju- gate is shortened (less than 11.5 cm [4.5 inches]). Ab- normal presentations such as face and shoulder pre- sentations increase this problem. Midplane contractures are the most common cause of pelvic dystocia. Fetal descent is arrested (stops), and a cesarean birth is com- monly done. Outlet contracture exists when the pubic arch is narrow. If uterine contractions continue when the passageway is obstructed, uterine rupture can oc- cur, placing both the mother and fetus at risk. A com- mon minor obstruction of the passageway is a dis- tended bladder. Catheterization may be needed if the woman cannot void. Scar tissue on the cervix from previous infections or surgery may not readily yield to labor forces to efface FIGURE 15-1 McRoberts maneuver to relieve shoulder and dilate. A cesarean birth may be indicated when an dystocia. The woman fl exes her thighs sharply against her abnormality of the passageway prolongs or impedes abdomen to straighten the pelvic curve. A squat position has a the progress of labor. similar effect and adds gravity to pushing efforts.

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Frank breech Full (complete) breech Single footling breech FIGURE 15-2 Types of breech presentations.

During labor, the fetal descent is slow because the delivery may be done, but fetal hypoxia and injury breech is a less effective dilating wedge than the fetal are always risks. head. The buttocks, legs, and feet are softer than the Persistent Occiput Posterior Position. Persistent occiput head and therefore exert less pressure on the cervix. posterior positions occur when the back of the fetal Cord prolapse occurs more often during breech birth head (the occiput) enters the maternal pelvis and is and increases the risk of birth trauma because the but- directed toward the back (posterior) of the maternal tocks (presenting part) are smaller than the head and pelvis instead of toward the front (anterior). When this do not fi t as tightly into the pelvis. The risk of postpar- position occurs, labor is usually prolonged because, in tum hemorrhage is also increased. The three basic the process of internal rotation, the head must rotate types of breech presentation are shown in Figure 15-2. further. A maternal hands-and-knees position may Alternatives to vaginal birth of the fetus in breech pre- help the fetus rotate from a posterior to an anterior sentation are external cephalic version (ECV) or a ce- position (Figure 15-4). A squatting position helps sarean birth, in which the fetus is delivered abdomi- straighten the pelvic curve and aids in rotation. Some- nally. The woman should be fully informed of her times the woman is asked to push while lying on her options and the risks involved in each. side, which may help the fetus rotate to an anterior The presence of in the amniotic fl uid in position. If the occiput remains posterior, the baby is breech presentations is not necessarily a sign of fetal born with the face upward. The woman usually has a distress but results from pressure on the fetal abdomi- great deal of back discomfort because the baby’s head nal wall and buttocks. Fetal heart tones are best heard presses against her sacrum during rotation. Sacral at or above the maternal umbilicus. Forceps are some- counter pressure and back rubs are appreciated by the times used to deliver the after-coming fetal head. In a woman during labor. breech delivery, when the lower body is born, the um- bilical cord extends above the fetal head and is at risk External Version of compression as the head passes through the bony External version is changing the fetal presentation af- vaginal canal. Birth of the head must occur quickly to ter 37 weeks’ gestation, usually from breech or trans- avoid hypoxia. The mechanism of labor in a breech verse lie to . Successful external presentation is shown in Figure 15-3. version can reduce a woman’s chance of having a ce- Face and Brow Presentation. In a face or brow presen- sarean birth. The risks of an external version are a pro- tation the diameter of the presenting part is larger lapsed umbilical cord and abruptio placentae. Con- than in a vertex or occiput presentation. It is a less traindications are uterine malformations, previous effective dilating wedge than the top of the fetal cesarean birth, disproportion between fetal size and head. The safest means of delivery of the baby in the maternal pelvic size, placenta previa, multifetal gesta- posterior face position is a cesarean birth. A forceps tion, and uteroplacental insuffi ciency.

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A B

D C

AVOID Overextension

Access to airway

E F FIGURE 15-3 Mechanism of labor in a breech presentation. A, The buttocks reach the perineum. Flexion of the fetal head is maintained. B, Traction to the fetal knee enables delivery of the leg. C, The fetal pelvis rotates as the second leg is delivered. D, As the scapula appears under the symphysis pubis, the arm is delivered. E, Gentle rotation of the shoulders facilitates delivery of the other arm. F, The fetus is quickly wrapped in a towel for control and slightly elevated. The fetal airway becomes visible at the perineum, and the head is delivered by fl exion.

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ness, establishing a trusting relationship with the mother and family, guiding the support person, and using pharmacologic and nonpharmacologic meth- ods of pain management.

INDUCTION OF LABOR AND AUGMENTATION Induction of labor refers to measures to initiate uter- ine contractions before they spontaneously begin. La- bor is usually induced because the benefi ts of termi- FIGURE 15-4 A hands-and-knees position assists the fetus in nating the pregnancy outweigh the benefi ts of rotating from left occiput posterior to left occiput anterior continuing the pregnancy for mother or fetus. Aug- position. mentation of labor is the use of an oxytocic drug after spontaneous but ineffective labor has begun. The woman and partner should be fully informed of risks Ultrasound guides fetal manipulations during the and benefi ts of these procedures. external version. Most physicians give the woman a tocolytic drug to relax the uterus. After the uterus is REASONS FOR INDUCTION relaxed, the physician presses on the abdomen to gen- Induction of labor is often performed because the delay tly push the breech out of the pelvis and toward the of delivery would place the woman or fetus at signifi cant mother’s side. The fetal head is pushed downward and risk. Maternal indications for induction include infec- to the opposite side. The tocolytic drug is stopped after tion (chorioamnionitis), PROM, and worsening medical the version is completed. Fetal heart rate and contrac- disorders (e.g., , diabetes melli- tions are monitored and the woman taught to report tus type 1, or chronic hypertension). Fetal indications signs of labor that may occur. include intrauterine growth restriction, postterm new- Maternal version is usually an emergency proce- born, and fetal demise. Elective induction for conve- dure that occurs in the delivery room. Most commonly, nience in planning child care, transportation, and birth it is performed during the vaginal birth of twins to attendants is a growing trend. Induction of labor is con- change the fetal presentation of the second twin. traindicated if the mother has active genital herpes, cephalopelvic disproportion, umbilical cord prolapse, CAM Therapy placenta previa, or vertical incision of the uterus from a Complementary and alternative medical (CAM) thera- previous cesarean birth. pies may play a role in versions. In traditional Chinese , the herb mugwort is used in a therapy call METHODS OF INDUCTION moxibustion. Incense cones of the prepared herb are CAM Therapy placed in the outer corner of the fi fth toenail (a median CAM therapies (see Chapter 23) for inducing labor have point of the body) and allowed to burn near the skin. become popular, and admission interviews should in- The heat and odor are believed to increase fetal activity clude asking the woman whether any practices have that promotes a breech version (Neri, Airola, Contu, et been used. Midwives sometimes recommend the use of al., 2004). See Chapter 23 for further discussion of CAM evening primrose oil (which converts to a prostaglandin therapies. compound), black haw, black cohosh, blue cohosh, or red raspberry leaves to induce labor (Gallagher, 2004). PSYCHE Their value in aiding cervical ripening or enhancing safe Psychologic factors have a strong effect on the prog- is still under investigation. Castor oil, ress of labor. The woman’s perceived fears of pain, hot baths, and enemas are not recommended and have lack of support, embarrassment, or violation of reli- no proven value in labor induction. Sexual intercourse gious rituals can cause the body to respond to the is commonly recommended to induce term labor in stress in ways that inhibit the progress of labor. Secre- many cultures. The belief involves the release of oxyto- tions of epinephrine as a response to stress inhibit cin resulting from breast stimulation, the release of nat- contractions and divert blood away from the uterus ural prostaglandin from the semen, and the stimulation to the skeletal muscle. Tense muscles result in less ef- of uterine contractions that result from female orgasm fective uterine contractions and a higher perception all contributing to labor induction. Acupuncture and of pain. Glucose used in the stress response reduces transcutaneous electrical nerve stimulation (TENS) may the energy supply available to the labor process. The stimulate release of natural and oxyto- nursing goal is to help the woman relax by adjusting cin, but their effectiveness as labor induction techniques the environment for maximum comfort and cleanli- is not supported by research data.

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Pharmacologic Methods. Prostaglandin (PGE2) gel is Cervical Ripening applied to the cervix before induction to soften and Induction of labor will be more successful if the cervix thin (ripen) the cervix. PGE2 gel may be administered is “ripe,” reducing the need for an emergency cesarean through a catheter into the cervical canal or applied to birth (Tenore, 2003). Cervical ripening, or maturation, a diaphragm that is placed next to the cervix. Oxytocin describes a series of biochemical events that result in a induction usually is not started for several hours to soft, pliable cervix. The cervical ripening is evaluated avoid . Side effects of PGE2, by the Bishop scale (Table 15-5). The American College which include vomiting, diarrhea, fever, and hyper- of Obstetricians and Gynecologists (ACOG) has rec- stimulation of the uterus, are not common but can oc- ommended that a Bishop score of 6 or more is neces- cur with gel application. The woman may be placed in sary to predict a successful outcome of labor induction. a modifi ed Trendelenburg position for 1 to 2 hours af- Techniques of cervical ripening include nonpharmaco- ter gel insertion to prevent leakage. Prostaglandin logic and pharmacologic methods. preparations include dinoprostone (Prepidil, Cervidil) Nonpharmacologic Methods. Nonpharmacologic meth- and misoprostol (Cytotec). Misoprostol has been rec- ods of cervical ripening include: ommended for use by the ACOG (2004) with special Stripping of membranes: The digital separation of guidelines. Uterine contractions and fetal heart rate the amniotic membranes from the lower uterine are monitored for at least 30 minutes after insertion. segment. The cervix must be dilated enough to Women who have asthma, glaucoma, or renal or liver allow penetration to reach the membranes. En- disease may not be candidates for this treatment. Cer- dogenous prostaglandins are released that stimu- vical ripening procedures usually reduce the dose of late oxytocin production. oxytocin needed for induction of labor. Amniotomy: The artifi cial rupture of the mem- branes (AROM). Membranes are ruptured by Oxytocin Induction and Augmentation piercing with an amniotic hook. The vertex must Oxytocin, a hormone normally produced by the poste- be engaged before this procedure is performed to rior pituitary gland, stimulates uterine contractions. prevent cord prolapse. The fetal heart rate should Oxytocin (Pitocin) is used to induce the labor process be monitored after an amniotomy, and the char- or to augment labor that is progressing slowly because acter, odor, and color of the amniotic fl uid should of ineffective uterine contractions. be documented. Before oxytocin administration is started, a vaginal Mechanical dilators: Dilators can be inserted into examination is performed to assess cervical dilation the cervix to progressively dilate the cervix and and effacement, fetal presentation and position, and release endogenous prostaglandins. This process fetal descent. The woman’s vital signs are assessed and is uncomfortable for the woman and has been re- recorded, and fetal well-being is evaluated. Continu- placed by hygroscopic dilators. ous EFM is started before and is continued during the Hygroscopic dilators: Laminaria species, a type of oxytocin infusion. desiccated seaweed; Lamicel, a synthetic dilator Oxytocin has an antidiuretic effect that can decrease containing magnesium sulfate in polyvinyl alco- urinary output and cause water retention. Maternal hol; or Dilapan (polyacrylonitrile) is inserted into water intoxication and fetal hyperbilirubinemia have the cervix, absorbs fl uid from surrounding tis- been associated with prolonged oxytocin infusions. sues, and then expands to cause cervical dilation The nurse should be alert for signs of water intoxica- (Gabbe, Niebyl, & Simpson, 2007). The dilator is tion, including headache, nausea and vomiting, de- usually left in place for 6 to 12 hours; the Bishop creased urinary output, hypertension, tachycardia, and score is then reevaluated. Nursing responsibilities cardiac dysrhythmias. The most common adverse ef- include documenting the number of dilators in- fects of oxytocin administration are uterine hyperstim- serted, assessing urinary retention, and monitor- ulation and reduced fetal oxygenation. Hyperstimula- ing fetal heart patterns and uterine contractions. tion may lead to uteroplacental insuffi ciency, fetal

Table 15-5 Bishop Scale*

SCORE DILATION (CM) EFFACEMENT (%) FETAL STATION CERVIX POSITION OF CERVIX 0 0 0-30 Ϫ3 Firm Posterior 1 1-2 40-50 Ϫ2 Medium 2 3-4 60-70 Ϫ1 Soft Anterior 3 5-6 80 ϩ1, ϩ2

NOTE: A point may be added to the score for preeclampsia and each prior . A point may be deducted from the score for a postterm pregnancy, nulliparity, or prolonged ruptured membranes. A high score (8 or 9) is predictive of a successful labor induction because the cervix has ripened, or softened, in preparation for labor. American College of Obstetricians and Gynecologists recommends a score of 6 or above before induction of labor. Modifi ed with permission from Norwitz, E., Robinson, J., & Repke, J. (2002). Labor and delivery. In S. Gabbe, J. Niebyl, & J. Simpson (Eds). Obstetrics: Normal and problem pregnancies (4th ed., p. 375). London: Churchill Livingstone.

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compromise, uterine rupture, and a very rapid labor with potential uterine or cervical lacerations. Oxytocin (diluted in an intravenous solution) is ad- ministered by a controlled infusion pump. During the oxytocin intravenous infusion the nurse should report any contractions lasting longer than 90 seconds, inter- vals between contractions less than 60 seconds, and nonreassuring fetal heart rates. Oxytocin should not be administered without a physician readily available who is capable of performing an emergency cesarean birth. The nursing goals include assessing uterine ac- tivity, cervical dilation, and maternal-fetal response. (Right) mediolateral (Left) mediolateral The nurse assesses intake and output to prevent water Midline intoxication. Oxytocin is discontinued immediately and the primary health care provider notifi ed if uterine hyper- stimulation or nonreassuring fetal heart rate occurs. The health care provider explains the procedure to FIGURE 15-5 Episiotomy. Two types of incisions are midline the woman and advises her that frequent evaluations and mediolateral. will be necessary. Nursing care includes frequent peri- neal cleansing and linen changes to reduce the intro- duction of organisms and thus decrease the risk of in- formed when the fetal head is crowning, just before the fection and promote comfort. The side-lying position is birth of the fetus, to reduce the blood loss. recommended to increase placental perfusion. The If lacerations of the perineum occur, they are classi- woman’s vital signs should be taken and the external fi ed in one of four degrees: A fi rst-degree laceration fetal monitor evaluated frequently. extends through the skin and into the mucous mem- Nipple stimulation may be used to aid stimulation brane. A second-degree laceration extends farther, of labor (see Chapter 6). Terbutaline should be avail- reaching the muscles of the perineal body. In a third- able to stop labor induction if hyperstimulation of the degree laceration, the anal sphincter muscles and uterus or adverse fetal responses occur. Oxygen is ad- muscles of the perineum are torn. A fourth-degree lac- ministered by mask during induction, and the woman eration reaches into the anal sphincter muscles and an- is closely monitored. Failure to dilate more than 2 cm terior wall of the rectum. in a 4-hour period during active labor may be an indi- Measures used (especially by midwives) to enhance cation for cesarean birth. perineal stretching are application of warm com- presses, warm oil, and perineal massage. The warm compresses and perineal massage are thought to soften EPISIOTOMY and stretch perineal muscles and may reduce the need for an episiotomy. Although episiotomies are used when indicated, every Often, after episiotomy repair, an ice bag is applied effort is made to retain an intact perineum and reduce to the incision to reduce swelling. Other nursing mea- perineal trauma. An episiotomy is a surgical incision sures used for an episiotomy are discussed in Chapter made into the perineum to permit easier passage of the 13. Kegel exercises are encouraged after healing to re- fetus. It is indicated when lacerations of the perineum, gain muscle tone. vagina, or cervix might occur. It is performed to shorten the second stage of labor, relieve compression on the fetal head, and facilitate breech and forceps births. Epi- siotomy is not routinely performed but should not be ASSISTED VAGINAL DELIVERY routinely avoided. Two types of episiotomies are (1) the median (midline) episiotomy, which extends from the FORCEPS-ASSISTED BIRTH posterior fourchette of the vagina downward but not Forceps are curved metal instruments used by the phy- to the rectal sphincter; and (2) the mediolateral episi- sician to provide traction to deliver the baby’s head, otomy, which is an incision made on an angle to the assist the rotation of the head, or both (Figure 15-6). woman’s right or left side (Figure 15-5). An episiotomy These instruments may be used to deliver preterm is thought to heal more satisfactorily than a laceration. newborns to prevent undue pressure from being placed A median episiotomy is considered to be less uncom- on the fragile fetal skull by continued contractions. fortable and heals better than a mediolateral incision. They are also used to shorten the second stage of labor However, a median incision can extend into the rec- when the mother is exhausted and cannot effectively tum. A regional or local block is given before the episi- bear down. Sometimes regional or general anesthesia otomy is performed. Ideally, the episiotomy is per- has affected the motor innervation and the mother can-

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not push effectively. Forceps are also used to deliver compresses after 12 hours aid in absorption of edema the baby as soon as possible when fetal distress occurs. and hematoma. The cervix must be completely dilated and the fetus’s head low or visible on the perineum (low forceps de- VACUUM EXTRACTION livery) (Box 15-1). Forceps should be applied only by a Vacuum extraction is used as an alternative to forceps skilled physician. A Foley catheter is inserted before application. Vacuum extraction involves applying a cup, forceps delivery to prevent bladder injury. The obstet- called a vacuum extractor, to the fetal head and with- ric forceps has a cephalic curve to fi t over the fetal head drawing air from the cup. This creates a vacuum within and conforms to the curve of the maternal pelvis. Piper the cup, which secures it to the fetal head. Traction is forceps are used for the head in a breech delivery after applied during the uterine contractions, and the fetal the body is born. head is delivered (Figure 15-8). The indications for vac- Maternal complications of a forceps delivery include uum extraction are the same as for forceps deliveries. lacerations of the birth canal and perineum with in- creased blood loss. The newborn can have bruising and edema of the scalp, potential cephalhematoma, and intracranial hemorrhage. In a diffi cult forceps ap- plication, temporary or even permanent paralysis of a facial nerve may occur. The nurse explains the procedure to the woman and helps the woman use breathing techniques to avoid pushing during application of forceps. The health care provider applies traction during a contraction as the woman pushes. After birth, the newborn is assessed for bruising, edema, and other trauma. Bruising and edema in the newborn, called forceps marks, resolve without treatment (Figure 15-7). The mother is ob- served for bleeding, which will be a brighter red than lochia rubra. Cold application to the perineum for the FIGURE 15-7 Note the “forceps mark” on this newborn’s fi rst 12 hours reduces edema and lessens pain. Heat face. This bruise will resolve without intervention in a few days.

FIGURE 15-6 Application of obstetric forceps (top arrow) and direction of pull during a contraction.

Box 15-1 Criteria for Forceps Delivery • Membranes ruptured • Cervix fully dilated • Fetal head below the ischial spines or on the perineum • Empty bladder • Analgesia adequate FIGURE 15-8 Vacuum extractor for assisted vaginal delivery.

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Side effects of vacuum extraction include edema and delivery. When uterine rupture is associated with and bruising to the fetal scalp. Risks to the fetus in- a previous cesarean birth, the rupture occurs at the site clude cephalhematomas, scalp lacerations, and subdu- of the previous surgical scar. Aggressive or poorly su- ral hematoma. Maternal complications are uncommon. pervised induction of labor may be responsible for The woman should be informed about the medical rupture of the uterus. A prolonged labor with fetopel- procedure. The fetal heart rate should be monitored. vic disproportion is another cause. Parents need to be advised that the caput A clue to a pending rupture is persistent uterine (edema) will disappear in approximately 2 or 3 days. contractions without periods of relaxation. The nurse Assessment of the newborn includes continued obser- must report uterine contractions lasting more than 90 vation for cerebral hemorrhage and injury. seconds. A relaxation period is necessary to maintain fetal oxygenation. Close EFM can identify women at risk for rupture. As labor progresses, the woman might POSTTERM LABOR AND BIRTH have a sharp pain in the suprapubic area. With severe bleeding, symptoms of shock occur. The major compli- Postterm birth is the birth of a newborn beyond 42 cations are maternal hemorrhage and fetal death. Treat- weeks’ gestation. The primary maternal risk related to ment usually consists of an immediate uterine surgery postterm birth is a large newborn, which places the and possible hysterectomy. Blood transfusions may be woman at risk for a dysfunctional labor, forceps- needed. assisted birth, lacerations in the vaginal canal, and a potential cesarean delivery. Fetal risks include the pos- sibility of birth trauma, CPD, and hypoxia caused by HYDRAMNIOS an aging placenta that begins to deteriorate after 42 weeks’ gestation. When placental insuffi ciency is pres- Hydramnios (also called ) is an exces- ent, the risk of fetal hypoxia increases. sive amount of amniotic fl uid, greater than 2 L. When The management of postterm labor is controversial. hydramnios is present, congenital anomalies often ex- Induction of labor is suggested at 42 weeks’ gestation. ist, particularly those of the fetal gastrointestinal tract. Tests for fetal well-being are performed, including an It is associated with fetal malformations that affect fe- NST and biophysical profi le with ultrasound scanning tal swallowing and voiding. During pregnancy the fe- to assess fetal movements, fetal breathing, and amni- tus voids in and swallows the amniotic fl uid. Any fetal otic fl uid volume. may be performed to anomaly that upsets this exchange can result in an ex- detect meconium in the amniotic fl uid (see Chapter 5). cessive amount of amniotic fl uid. When hydramnios A postmature newborn has a long lean body, long fi n- develops, the uterus overdistends. This may cause pre- gernails, and dry, peeling skin (see Chapter 16). term labor and place the woman at a greater risk for postpartum hemorrhage. Hydramnios can be diag- nosed by ultrasound (an amniotic fl uid index [AFI] PRECIPITATE LABOR greater than 20) (Gabbe, Niebyl, & Simpson, 2007). Re- moval of excess amniotic fl uid may cause abruptio pla- Precipitate labor is a labor completed in less than 3 centae as the uterine size is decreased, or prolapse of hours from the time of the fi rst true labor contraction the umbilical cord. Psychologic support for the mother to the birth of the baby. Because the labor is rapid, ma- is an important nursing responsibility. Amniocentesis ternal and fetal complications can occur. If the uterus may be done to avoid a preterm labor caused by an has little relaxation between contractions, the intervil- overdistended uterus. lous blood fl ow may be impaired enough to cause fetal hypoxia (lack of oxygen). Also, rapid passage of the fetal head through the birth canal may result in fetal OLIGOHYDRAMNIOS intracranial hemorrhage. The woman may also have cervical, vaginal, or perineal lacerations. Ideally, a phy- Oligohydramnios is a decreased amount of amniotic sician will be available in the facility to assess the fl uid (an AFI less than 5) (Gabbe, Niebyl, & Simpson, woman and newborn and record the fi ndings. The 2007). It is associated with fetal renal anomalies and in- emergency delivery of the newborn by a nurse is dis- trauterine growth restriction. Oligohydramnios places cussed in Chapter 7. the fetus at risk for impaired musculoskeletal develop- ment because of the inability to move freely in the uterus and tangling of the long cord around an extremity, or UTERINE RUPTURE cord compression from twisting or kinking, resulting in fetal distress. Oligohydramnios can be detected by ultra- Uterine rupture is rare; however, it represents an emer- sound, which detects less than 1 cm of fl uid in a prede- gency condition because it causes severe maternal termined pocket or quadrant of the uterus (AFI). During bleeding and shock. It occurs most often during labor labor an amnioinfusion (a transcervical instillation of

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warm sterile saline into the uterus) may be done if mem- • With sterile gloved hand, pushing fetal present- branes have ruptured to prevent cord compression and ing part away from the cord relieve severity of variable decelerations. Fetal monitor- • Starting oxygen 8 to 10 L/min by mask ing and maintaining a clean, dry bed for the mother are • Closely monitoring fetal heart rate by EFM important nursing responsibilities. • Preparing for rapid vaginal delivery or cesarean birth If the cord protrudes, the nurse should apply sterile PROLAPSED UMBILICAL CORD saline-soaked towels to prevent drying of the cord and to maintain blood fl ow until the infant is delivered. Prolapsed umbilical cord occurs when the umbilical cord precedes the fetal presenting part. This condition is more likely to occur when there is a loose fi t between AMNIOINFUSION the fetal presenting part and the maternal pelvis when the membranes have ruptured. This circumstance Amnioinfusion is a procedure during which normal sa- leaves room for the cord to slip down (prolapse) (Fig- line or lactated Ringer’s solution is instilled into the am- ure 15-9). The cord can be alongside or ahead of the niotic cavity through a catheter introduced transcervi- presenting part. It may be occult (not palpable on vagi- cally into the uterus during labor. It is performed to nal examination), be inside the vagina, or even extend correct oligohydramnios or reduce thickly stained me- below the vulva. Because compression of the cord be- conium in the amniotic fl uid and to minimize cord com- tween the presenting part and the bony pelvis greatly pression. An infusion pump should be used so that fl ow decreases the fl ow of oxygen to the fetus, prolapse of rate is controlled and the amount of infused fl uid can be the cord can interfere with fetal oxygenation. accurately documented. The uterus should be moni- Factors that contribute to cord prolapse are (1) rup- tored for overdistention and elevated resting tone, ture of membranes before the fetal head is engaged, which can cause changes in the fetal heart rate. Because carrying a loop of the umbilical cord into the pelvis or the fl uid infused will constantly leak out, nursing mea- vagina; (2) a small fetus; (3) breech presentation; sures to maintain comfort and dryness should be used. (4) transverse lie; (5) hydramnios; (6) an unusually Amnioinfusions with hypertonic solutions are used as a long cord; and (7) multifetal pregnancy. Signs include technique of inducing before 20 weeks’ gesta- prolonged variable decelerations evidenced on the fe- tion (Gabbe, Niebyl, & Simpson, 2007). tal monitor, along with a baseline fetal bradycardia. Prompt actions must be taken to relieve cord com- pression and increase fetal oxygenation until help ar- MULTIFETAL PREGNANCY rives. Nursing interventions include: • Placing the woman’s hips higher than her head Multifetal pregnancy is the term for two or more fe- by (1) knee-chest position (Figure 15-10), (2) Tren- tuses in utero. Types of multifetal pregnancies are dis- delenburg position, or (3) side-lying position cussed in Chapter 3. A positive diagnosis of more than with hips elevated on pillows one fetus is made by ultrasound. Preterm labor is com- mon because of overdistention of the uterus. There is an increased frequency of anemia, hypertension, and hem- orrhage. The woman is more likely to hemorrhage be- cause of overdistention of the uterus; therefore a multi- fetal pregnancy poses greater risk than a single fetus. Twins may be in various positions; one may be breech and the other vertex. The labor may be normal or prolonged. During the birth the nurse should be prepared to identify each baby at the time it is born. A cesarean birth may be necessary if the cord has pro- lapsed, if one baby is malpresenting, or if more than two are present. The nursing care of the woman after the babies are born is the same as for other women, except the nurse is aware of the greater risk for post- partum hemorrhage. The incidence of multifetal pregnancies has in- creased because of the popularity of fertility treatments (assisted reproductive technology [ART]) such as in vi- tro fertilization. Some complications can occur with multifetal pregnancies such as twin-to-twin transfu- FIGURE 15-9 Prolapsed umbilical cord. sion syndrome, in which one twin transfuses its blood

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A gloved hand in the vagina pushes the fetus upward and off the cord.

Knee-chest position uses gravity to shift the fetus out of the pelvis. The woman’s thighs should be at right angles to the bed and her chest flat on the bed.

The woman’s hips are elevated with two pillows; this is often combined with the Trendelenburg (head down) position. FIGURE 15-10 Nursing interventions when the umbilical cord prolapses. Maternal positioning and pushing the fetus away from the cord can relieve pressure on the prolapsed umbilical cord until delivery can take place.

through a shunt to the other twin. This results in one preserve the life or health of the mother and her fetus. twin with intrauterine growth restriction and anemia, The incidence of cesarean births has increased dramat- whereas the other twin can be larger or have heart fail- ically in the past several years. According to the Na- ure because of circulatory overload. Another complica- tional Center for Health Statistics (2006), the 2004 rate tion involves the death of one twin in utero while the for cesarean births in the United States was over 29% other twin survives. Reabsorption of the tissues of the and the number of women having a vaginal birth after dead twin can predispose the mother to develop dis- a cesarean birth (VBAC) was at an all-time low of seminated intravascular coagulation (DIC) (Gabbe, 16.5%. Some reasons cited for the increase include in- Niebyl, & Simpson, 2007). creased detection of fetal problems from the use of Multifetal pregnancy reduction may be necessary EFM, an increase in the number of pregnancies at an when ART results in four or more fetuses and survival older age, and the high incidence of repeat cesarean of all are at risk unless some are selectively aborted. births. A national goal of Healthy People 2010 is to re- The remaining twins or triplets have a good chance of duce the rate of cesarean births to 15%. survival (Gabbe, Niebyl, & Simpson, 2007). Vaginal de- livery is advocated for vertex presentation of a twin, Cesarean Birth on Demand but a cesarean is indicated if presentation is not vertex Part of the increase in the rate of cesarean birth is or more than two fetuses are present. thought to be due to maternal request for cesarean de- livery rather than medical indication for delivery (Na- tional Institutes of Health [NIH], 2006). The NIH states CESAREAN BIRTH that elective cesarean births are not recommended for women who desire several children because the risk of Cesarean birth is a surgical procedure in which the placenta previa or placenta accreta rises with each suc- birth is accomplished through an abdominal and uter- cessive pregnancy after a cesarean birth. Placenta pre- ine incision. The basic purpose of a cesarean birth is to via may result because the placenta generally cannot

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attach at the site of a scar and so may attach in a lower the upper segment of the uterus. The choice of inci- segment of the uterus (see Chapter 14). If the placenta sion affects the woman’s opportunity for a subsequent does attach at the scar site, it may not release from the vaginal birth and her risks of a ruptured scar with a site after delivery, resulting in placenta accreta. subsequent pregnancy. An incision in the body (clas- sic, or upper part) of the uterus is problematic because Indications of potential rupture; therefore a future vaginal birth is Four categories are responsible for 75% to 90% indica- contraindicated. The lower uterine segment incision tions for cesarean births: dystocia, repeat cesarean, most commonly used is a transverse incision, al- breech, and fetal distress. Other indications for a cesar- though a low vertical incision may be used (Figure ean birth are active herpes viral infection; prolapsed 15-11). umbilical cord; medical complications, such as gesta- tional hypertension; placental abnormalities, such as placenta previa and abruptio placentae; and fetal anomalies, such as hydrocephaly (Box 15-2). Box 15-2 Indications for Cesarean Birth

Surgical Techniques • Previous cesarean birth • Failed trial of labor The skin incisions for a cesarean birth are either trans- • Fetal distress verse (Pfannenstiel’s) or vertical; these are not indica- • Uncontrollable third-trimester bleeding tive of the type of incision made into the uterus. The • Placenta previa transverse incision is made across the lowest part of • Abruptio placentae the abdomen. Because the incision is made just below • Cephalopelvic disproportion the pubic hair line, it becomes almost invisible after • Fetal malpresentation healing. The major limitation of this incision is that it • Prolapsed cord does not allow extension of the incision if needed. • Medical complications of pregnancy, such as maternal heart disorder The vertical incision is made between the navel and • Failure of labor to progress the symphysis pubis. This type of an incision is • Active herpes simplex virus infection quicker and is preferred in cases of fetal distress. • Postmaturity (with failed induction) Uterine incisions are either in the lower segment or in

SKIN INCISION UTERINE INCISION

Vertical through skin Vertical through uterus

Horizontal through skin (first skin crease under hairline)

Vertical through lower uterine segment

Horizontal through skin (first skin crease under hairline)

Horizontal through uterus (lower uterine segment) FIGURE 15-11 Various incisions used for cesarean births. A vertical incision in the skin and the uterus is called a classic incision. A horizontal incision through the lower uterine segment is most favorable for a trial of labor (vaginal birth after cesarean) in the next pregnancy.

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Niebyl, & Simpson, 2007). Removal (clipping or shav- Complications and Risks ing) of abdominal hair is only indicated when the hair Cesarean births are not without risks for both mother will interfere with closing and suturing the wound. and fetus. Maternal complications include aspiration, Routine skin shaving has been shown to predispose pulmonary , hemorrhage, urinary tract infec- the woman to postoperative wound infection. An in- tion, injuries to the bladder or bowel, wound infec- dwelling Foley catheter is inserted to keep the bladder tions, thrombophlebitis, and complications related to empty during surgery, which reduces the risk of injury anesthesia. Risks to the fetus include preterm birth (if to the bladder when the incisions are made. An ant- was not assessed properly), fetal inju- acid is administered intravenously to decrease stom- ries, and respiratory problems resulting from delayed ach acids, which could cause pneumonia if the woman absorption of lung fl uids. should vomit and aspirate during surgery. Laboratory reports are reviewed, including blood type and cross- Preparation for Cesarean Birth match, Rh, complete blood cell count, and urinalysis. Because cesarean birth is common, this method should Although property and valuables are secured, often be an integral part of education classes. the mother wears her eyeglasses to the operating room Couples need to discuss their specifi c needs and de- because she will be awake, and seeing clearly will aid sires with their physician or nurse-midwife. in bonding with her infant (Figure 15-12). Women and their partners have time for psycho- The fetal heart rate is recorded with electronic mon- logic preparation when they know that they are going itoring until the infant is delivered. Routine preopera- to have a cesarean birth. These women appear to cope tive teaching, including coughing, deep breathing, and with the recovery from surgery better than those who ambulating postoperatively, is done if time permits have an unplanned cesarean birth. Women having (Box 15-3). The use of spinal anesthesia reduces the emergency or unplanned cesarean births have abrupt need for vigorous newborn resuscitation that might be changes in the expectations for birth, postbirth care, necessary with general anesthesia, which crosses the and the care of the newborn at home. The woman may placental barrier. An infant warmer and resuscitation approach surgery exhausted and discouraged with her equipment should be on hand and the pediatrician no- labor. Time for explanations about the procedures for tifi ed. Preparing the woman for postoperative care ex- the surgery is often limited. Because procedures for the pectations is a nursing responsibility. The positive as- surgery must be performed quickly, both the woman pects of a cesarean birth should be emphasized and and her family may have high anxiety levels. These family support offered. women need adequate psychologic support. It is im- Newborn Care. A nurse from the newborn nursery portant to explain what is being done and for the nurse and a pediatrician are typically present in the operat- to verify informed consent was obtained. ing room to assist in the care of the newborn when delivered. A heated crib and resuscitation equipment Nursing Care are readily available. In most hospitals the father or Preoperative Care. The preoperative nursing care in- partner can be with the mother during the cesarean cludes all the usual procedures for preparing a patient birth. for surgery. The woman receives nothing by mouth to After the baby is born, the Apgar score and identifi - reduce the risk of aspiration. An intravenous infusion cation are recorded, the newborn is moved to a radiant through a wide-bore catheter is started. The hair on warmer to prevent chilling, and the skin temperature the skin of the abdomen is considered sterile (Gabbe, probe is applied. The mother and partner are given an

A B FIGURE 15-12 A cesarean birth. A, Spinal anesthesia is administered. B, The anesthesiologist reassures the woman. (Courtesy Pat Spier, RN-C.) Continued

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C D

E F

G H

I J FIGURE 15-12, cont’d A cesarean birth. C, The nurse cleanses the abdominal skin. D, The partner converses with the woman. E, An abdominal incision is made. F, The newborn’s head is lifted out of the uterus. G, The newborn’s body is lifted out of the uterus. H, The newborn is suctioned with a bulb syringe while the cord is clamped and cut. I, The placenta is lifted out of the uterus. J, Mother, partner, and newborn get acquainted. (Courtesy Pat Spier, RN-C.)

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Box 15-3 Nursing Care Summary of the Woman Having anxieties. Special effort to reduce postoperative pain Cesarean Birth and promote bonding with the newborn is important. Early ambulation is encouraged to reduce respira- BEFORE SURGERY tory and circulatory complications. As a rule, the • Assess when she last had oral intake. woman with a cesarean birth has less lochial fl ow, most • Explain what to expect with procedure. • Witness informed consent. likely because of the removal of some of the uterine • Monitor intravenous infusion. decidua during the surgical procedure. The intrave- • Cleanse abdomen. nous infusion may be maintained until the woman is • Insert indwelling urinary catheter. afebrile, has resumption of bowel sounds, and is toler- • Administer medications as ordered (antacid and ating fl uids. The intravenous infusion often contains antibiotics). oxytocin to keep the uterus well contracted. The in- • Verify blood type, cross-match, and urinalysis reports. dwelling urinary catheter is normally maintained until DURING RECOVERY PERIOD the intravenous fl uids are discontinued. Wound dress- • Start procedures related to postanesthetic period ings may be removed after the fi rst day. (pulse oximeter, oxygen administration, cardiac Analgesic measures for pain at the incision site may monitor). be given every 3 to 4 hours, or patient-controlled anal- • Assess fundus for fi rmness, height, and location per gesia (PCA) or epidural narcotics may be prescribed by protocol; massage fundus if poorly contracted the physician. Other comfort measures such as posi- (boggy). tion change and splinting the incision with pillows are • Observe vaginal bleeding for color, amount, and con- demonstrated. Deep breathing and coughing at fre- sistency (presence of clots). quent intervals are encouraged. • Monitor abdominal wound for healing. • Monitor vital signs every 15 minutes for fi rst hour, Discharge teaching includes information about every 30 minutes in second hour, then hourly until wound care, personal hygiene, breast care if breast- transfer to postpartum unit. feeding, bathing, diet, exercise and activity restrictions, • Determine urinary output; check catheter and tubing sexual activity, contraception, medications, signs of for patency (intake and output). complications, and newborn care. The Newborns’ and • Assess for bowel sounds and passage of fl atus. Mothers’ Health Protection Act of 1996 ensures a mini- • Change woman’s position hourly (if no contraindi- mum hospital stay of 96 hours for cesarean births. Af- cations). tercare can be enhanced by referral to home care re- • Have woman breathe deeply and cough frequently. sources. The nurse assesses the need for continued • Administer prescribed medication for pain. support or counseling and provides a telephone num- • Encourage early ambulation on fi rst day and shower- ber to call the hospital if needed. ing on second day. Vaginal Birth After Cesarean A trial of labor and a vaginal birth after cesarean (VBAC) are recommended by the ACOG for women opportunity to see, touch, and, depending on the con- who have had a previous cesarean birth by low trans- dition of the newborn, hold the newborn. verse incision. Labor and vaginal birth is not recom- Postoperative Care. After surgery the woman is taken mended if a previous fundal scar (classic cesarean inci- to the recovery room. Recovery room care includes sion) or evidence of CPD is present. Consent for VBAC observing the fi rmness of the uterus and the amount of should be discussed with the health care provider and bleeding from the vagina and assessing the abdominal the couple based on accepted risk factors. incision. Vital signs are taken every 15 minutes for 1 to The labor should occur in a health care facility that 2 hours or until the woman is stable. In addition, the is equipped and staffed to conduct a cesarean birth if woman receives the usual postoperative care. The necessary. Intrapartum care of the woman is essentially woman is given oxytocin intravenously to stimulate the same as for any woman in labor. Close observation the uterus to contract and reduce the blood loss. She is of fetal status and uterine contractions is maintained given analgesic medications to promote comfort. throughout the labor process. The use of cervical rip- The newborn is brought to the parents as soon as ening is not recommended, but augmentation with possible to facilitate bonding and attachment. Breast- oxytocin can be done with close monitoring. The 2004 feeding can be initiated. The woman may be trans- ACOG guidelines for VBAC include: ferred to the postpartum unit after 1 to 2 hours or when • One previous cesarean birth with transverse her condition is stable. Providing emotional support to uterine incision the mother and partner after a cesarean birth is essen- • Documented adequacy of the pelvis tial. Feelings of anxiety, guilt, and inadequacy may • Availability of the facilities to perform a cesarean prevail. Therapeutic communication helps clear up birth within 30 minutes fears and misunderstandings, and the woman should • Provision of EFM be encouraged to verbalize her fears and express her • Availability of intravenous access

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Women who have spontaneous labor have a much • Augmentation of labor is the use of oxytocin drugs lower incidence of uterine rupture than women who to stimulate labor when uterine contractions are inef- undergo labor induction. Women who have successful fective. VBACs have lower incidence of infection, less blood • Cervical ripening is performed to soften the cervix loss, and reduced health care costs compared with before starting an induction of labor. One method is inserting PGE into the cervical canal. women who have repeat cesareans. 2 • Amniotomy, or artifi cial rupture of membranes, usu- ally initiates labor within 12 hours of rupture in the Key Concepts near-term woman with a favorable cervix. • An episiotomy is a surgical incision made into the perineum to permit easier passage of the fetus. • Preterm labor is the onset of uterine contractions • Vaginal delivery with forceps or vacuum extraction resulting in cervical dilation and effacement between provides traction to deliver the baby’s head, assist the 20 and 37 weeks’ gestation. rotation of the head, or both. • Management of preterm labor includes assessment • Postterm labor and birth refer to a fetus beyond 42 of uterine activity and cervical changes, bed rest, weeks’ gestation. hydration, use of tocolytic agents, fetal surveillance, • Precipitate labor is rapid and lasts less than 3 hours. and management to promote fetal lung maturity. • Hydramnios (polyhydramnios) occurs when there is Home care management with a HUAM is performed excessive amniotic fl uid. It is associated with fetal in selected cases. malformations that affect fetal swallowing and voiding. • PROM occurs when the membranes rupture before • A prolapsed umbilical cord occurs when the cord the labor has started. precedes the fetal presenting part. • Dystocia is diffi cult and often prolonged labor. • A VBAC is suggested for women who have had a • Dystocia is suspected when there is a lack of labor previous cesarean birth by low transverse uterine progression in cervical dilation and slow advancement incision. A trial of labor is recommended, and the in fetal descent. It is caused by a problem with power woman is closely monitored. VBAC has decreased the (contractions), passenger (fetal position), passageway incidence of cesarean births. (small or obstructed pelvic path), or psyche. • CPD occurs when the fetus is too large to pass through the normal pelvis or the maternal pelvic diam- Go to your Companion CD-ROM for an Audio Glossary, Video eters are too small to allow passage of a normal-size Clips, and 3-D Animations. fetus. A cesarean birth may be necessary. • External version is the turning of the fetal presen- Be sure to visit the companion Evolve tation from a breech or transverse lie to cephalic. site at http://evolve.elsevier.com/Leifer/maternity for WebLinks Ultrasound guides fetal manipulations during the and additional online resources. procedure. • Induction of labor refers to measures to initiate uter- ine contractions.

CRITICAL THINKING ACTIVITIES

1. A woman is 20 years old with her fi rst pregnancy, and 2. A woman began spontaneous labor at 6 AM, and by 7 PM her fetus is in persistent occiput posterior position. She she had made no labor progress. Her cervical dilation is in labor with contractions every 3 to 4 minutes, her has not progressed beyond 4 cm. What reasons could membranes are intact, and she is having severe back- you give for her labor not progressing? ache with each contraction. If she asks you why she is having such severe back pain during her labor, how would you answer her?

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