Childbirth at Risk

Care of the Woman at Risk Because of Psychological Disorders

• Prevalence of psychological disorders of adults in the U.S. is 26.2%

• Alteration in thinking, mood or behavior

Depression

• More women are affected than men• CNS imbalance in serotonin & other

neurotransmitters• Unable to process information• Unable to concentrate• Fatigue, sleep deprivation• Overwhelmed by labor process• Unworthy of motherhood• Hopelessness

Effect on Labor

• Unable to concentrate/process info from healthcare team

• May begin labor fatigued or sleep deprived• Labor process may overwhelm the woman

physically & emotionally-no energy• May appear irritable or withdrawn due to

inability to articulate feelings of hopelessness or “unworthiness of motherhood”

Bipolar Disorder

• Higher risk of suicide

• Women with a previous diagnosis of bipolar depression are at greater risk for developing a mood disorder in the postpartum period

• Postpartum psychosis is more common in women with bipolar disorder

Anxiety Disorders

• Panic disorder, OCD,PTSD, generalized anxiety disorder, phobias

• Cause a wide range of sx in the laboring woman: terror, SOB, CP, weakness, faintness, dizziness (exclude other dx)

• Labor may trigger flashbacks, avoidance behavior, anxiety sx.

• Severe sx to vague feeling “something is wrong”

Clinical Therapy

• Provide support

• Decrease anxiety

• Orient to reality

• Sedatives/analgesia (decrease pain may decrease psychological sx)

• Psychiatric support

Dystocia

• Abnormal labor pattern• Problem with the 3 Ps• Most common problem is dysfunctional

uterine contractions resulting in prolonged labor

• Friedman curve: 4cm in active labor-1cm/hr for primips, 1.5 cm/hr for multips

• Variations: protracted labor & arrest of labor (no change for 2 hours)

Hypertonic Labor Pattern

• Ineffectual uterine contractions of poor quality occur in the latent phase and resting tone of the myometrium increases

• Painful, ineffective contractions become more frequent prolonging latent phase

• Management: bed rest and sedation to promote relaxation and reducpain

• Nursing comfort measures: position change, hydrotherapy, mouthcare, linen change, relaxation exercises, education

Clinical Management

• Consider CPD (station) “out of the pelvis”

• If no CPD, consider amniotomy and Pitocin augmentation

Active vs Expectant Management

• AMOL: amniotomy, timed cervical checks, augmentation of labor with IV pitocin

• Expectant management: Labor considered a normal process and allowed to progress without automatic intervention

Nursing Care and Management

• VS• Labor pattern• Cervical progress• Fetal status• Vtx pressing down on cx without descent =

caput, caput increases with no progress• Maternal hydration: I & O• Monitor for infection

Precipitous Labor and Birth

• L & D occurs within 3 hours

• Maternal risks: abruptio placenta, lacerations, PPH

• Fetal risks: oxygenation may be poor-meconium stained AF may be aspirated, low Apgar scores, trauma

• Know hx, assess laboring woman for rapid dilatation

Postterm Pregnancy

• Extends beyond 42 completed weeks of pregnancy

• 7% of all pregnancies in the U.S.• Cause – unknown, wrong dates• ? Dates: early sono• Maternal risks: labor induced, LGA, macrosomia,

forceps, vacuum, perineal damage, hemorrhage, c/s doubled (endometritis, hemorrhage, thromboembolic disease)

Postterm Pregnancy

• Fetal risks: placental changes, increased perinatal mortality, oligohydramnios, if decreased placental perfusion-SGA;

• IF no compromise-LGA or macrosomic, birth trauma, shoulder dystocia, prolonged labor, hypoglycemia seizures, respiratory distress, meconium staining-aspiration

Management of Postterm Pregnancy

• Starting at 40 wks: NST, BPP, AF index + NST usually twice weekly

• In labor, ongoing assessment, continuous EFM, note AF,

Fetal Malposition - POP

• Early labor 15%, at birth 5%• Maternal risk: intense back pain til rotation, 3rd or

4th degree laceration if born OP, higher incidence of operative deliveries (60% of women will have a c/s)

• Nursing assessment: back pain, abdominal depression, protracted labor, FHR heard laterally

• Nursing care: Position change! pelvic rocking

Face presentation. Mechanism of birth in mentoposterior position. Fetal head is unable to extend farther. The face

becomes impacted.

Types of cephalic presentations. A, The occiput is the presenting part because the head is flexed and the fetal chin is against the chest. The

largest anteroposterior (AP) diameter that presents B, Military (sinciput) presentation. C, Brow presentation.D, Face presentation.

Breech

• Overall incidence 4%, directly related to gestational age

• Frank breech most common 50-70%(term)

• Single or double footling breech 10-30% (preterm)

• Complete breech 5%

Frank breech

Incomplete (footling) breech

, Complete breech

On vaginal examination, the nurse may feel the anal sphincter. The tissue of the fetal buttocks feels soft.

Breech

• Associated with: placenta previa, oligo, hydrocephaly, anencephaly,multiples

• Higher incidence of cord prolapse, neonatal & infant mortality, mec aspiration

• Entrapment, head trauma, spinal injury

• ECV (external cephalic version) attempted at 37- 38 weeks

• Passage of mec normal in vag breech

Transverse Lie

Common in mutliples

More common in multips

Many convert to cephalic or breech by term

If still transverse ECV may be done

Persistent transverse lie requires a c/s after determining fetal lung maturity

Transverse lie. Shoulder presentation

Macrosomia

• More than 4500 g. (differs according to ethnic group)

• Obese women 3-4 times more likely• Association with pregestational and

gestational diabetes• Distention of uterus, overstretching leads

to dysfunctional labor & increased PPH• Increased risk perineal trauma, PPH,

infections, forceps, vacuum

Shoulder Dystocia

• ID macrosomic infant infant in labor

• McRoberts maneuver, lower mom’s head, apply suprapubic pressure

• Recognize: slow descent, turtle sign, excessive molding

• After the birth: examine for cephalhematoma, Erb’s palsy, fractured clavicle. Neuro/cerebral damage

McRoberts maneuver. A, The woman flexes her thighs up onto her abdomen

B, The angle of the maternal pelvis before McRoberts maneuver. C, The angle of the pelvis with McRoberts

maneuver.

Multiples

• Twins 3.2% of all pregnancies

• Triplets and higher 1.8%

• 33% monozygotic twins: genetically identical-highest risk for fetal demise, cord entanglement, twin-to-twin transfusion

• 25% of all twins are lost before the end of the first trimester

• Higher incidence of preterm birth

Complications Common with Multiples

• Spontaneous abortion• Gestational diabetes• Hypertension or preeclampsia 2.6x• HELLP• Acute fatty liver (severe coagulopathy, hypoglycemia, hyperammonemia

• Pulmonary embolism 6x• Maternal anemia• Hydramnios• PROM, incompetent cx, IUGR• Labor cx: PTL, uterine dysfunction, abn presentations,

operative delivery (forceps, c/s) PPH

Management

• Goals: promote normal fetal development, prevent maternal complication, prevent PTD, diminish

fetal trauma• US: frequent surveillance• PTL prevention: cervical checks start at 28 wks &

cervical measurements, fetal fibronectin equivocal. Bed rest and hospitalization to prevent PTL not supported by EBP

• Expect fundal height greater than wks gestation• Auscultate 2 heart beats• Wt gain 35-44# • Diet 135g protein & 1mg folic acid

Labor Management of Multiples

• c/s if presenting twin is not vertex

• External monitor A & B

• Internal monitor A & external monitor B

• Correctly identify A & B

• Anticipate PPH

Nonreassuring Fetal Status

• O2 supply insufficient to meet physiological demands of fetus

• Causes: cord compression, uteroplacental insufficiency, maternal/fetal disease

• Most common initial signs=meconium stained AF (vertex) changes in FHR( late, severe variable decelerations; rising baseline)

Interventions

• Change mother’s position

• Increase rate of IV infusion

• O2 via mask at 6-10 L/min

• Continuous EFM

• D/C pitocin if running

• Provide emotional support to woman, her partner, family-explanations: unexpected c/s

Placental Problems

• Abruptio placenta

• Placenta previa

• Accreta

Abruptio Placentae

• Premature separation of a normally implanted placenta: 0.5%-2%

• Risk factors: smoking, PROM, HTN, previous abruptio=10x higher risk

• Cause unknown: maternal HTN(44%), trauma ( 2-10%),fibroids, cocaine, high parity, short cord

• Marginal, Central (concealed bleeding), Complete• Retroplacental clot, blood invades myometrium, uterus

turns blue couvelaire uterus- hysterectomy• Large amts of thromboplastin are released triggering

DIC, fibrinogen plummets

Abruptio placentae. A, Marginal abruption with external hemorrhage. B, Central abruption with concealed

hemorrhage. C, Complete separation

Management

• Risk of DIC- evaluate coagulation profile• In DIC fibrinogen and platelet counts are decreased, PT

and PTT are normal to prolonged, fibrin split produces rise with DIC

• IV access (16 or 18 gauge), continuous EFM, c/s usually safest, T and X-M at least 3 units of blood, treat hypofibrinogenemia with cryo or FFP before surgery, may need CVP monitoring.

• Consider 2 IV lines, watch I & O, worrisome if output below 30 mL/hour

• Clot observation test at bedside (red top tube) if clot fails to form in 6 minutes fibrinogen level of less than 150 mg/dL is suspected, clot not formed in 30 minutes fibrinogen less than 100 possible

Placenta Previa

• The placenta is improperly implanted in the lower uterine segment. Implantation may be on a portion of the lower uterine segment or over the internal os.

• As the lower uterine segment contracts and dilates in the later weeks of pregnancy, the placental villae are torn from the uterine wall. Bleeding

Previa

• Cause: unknown; 1:200 preganacies• Risk factors: multiparity,increasing age,

accreta, prior c/s, smoking, recent abortion spontaneous or induced, large placenta

1. Total placenta previa: internal os covered completely

2. Partial placenta previa: internal os partly covered

3. Marginal placenta previa: edge of placenta is at the margin of the os

4. Low-lying placenta: implanted in the lower segment but does not reach the os

Placenta previa. A, Low placental implantation. B, Partial placenta previa. C, Total placenta previa

Management• Vasa previa: fetal vessels course thru the amniotic membranes and are

present at the cervical os

• Women present with bleeding, review records, get us, no vag exams (unless double set-up), consider cervical bleeding

• If less than 37 weeks & first bleeding episode-expectant management:

No vag examsBed rest with BRP Monitor bleeding, pain , UC, vs, FHRLabs: Rh, h&h urinalysisIV2 units blood available Betamethasone to facilitate fetal lung maturity

Prolapsed Cord

• An umbilical cord that precedes the fetal presenting part; cord falls or is washed down thru the cervix into the vagina and becomes trapped between the presenting part and the maternal pelvis

• Usually occult cord prolapse• Risks: breech, shoulder presentations,

LBW, multips with 5 or more births, multiples, amniotomy

Prolapse of the umbilical cord

Prolapsed Cord

• Mom: c/s, fetal death

• Fetus: bradycardia, variable decel

• Relieve the pressure by pushing back the presenting part, O2, EFM, IV, fill bladder, Trendelenberg,knee-chest, delivery

• Women at risk: not engaged & SROM or AROM, bed rest if ROM and not engaged

AFE

• Occurs when a bolus of amniotic fluid enters the maternal circulation and then the maternal lungs

• Cause unknown

• Mortality 60-80%

• 10% of all maternal deaths in the U.S.

“Vigorous contractions in a woman having her first baby can led to circumstances in which AFE is likely to develop.”

-Williams Obstetrics

• Cytotec causes unusually strong contractions, AFE is a known risk of using cytotec on a pregnant woman

AFE

• WE know that the rate of women dying around the time of birth has been increasing in the US for 25 years

• What about the rate of AFE?

• Evidence suggests that AFE related deaths are increasing as well with a clear connection with increasing use of uterine stimulant drugs

WHY?

• “Wild West” medicine

• Maternal mortality going up

• Slight decrease in perinatal mortality due not to a decrease in % of babies who die before they are born but rather to a slight decrease in the rate of babies who die shortly after birth owing to our Neonatal intensive care.

HX

DES

DES

• DES approved by FDA without testing

• 1947-1971 “wonder drug” 5 million US women take DES

• Popular regime 125 mg = 700 bcps

• 1962 declared ineffective for preg but used as a morning after pill

• 1971 alarming rates of vaginal cancer seen in DES daughters

cytotec

• “off-label”

• Not approved by…

Letter from Searle Warning Doctors Against Cytotec Birth Inductions August 23, 2000

Important drug warning concerning unapproved use of intravaginal or oral misoprostal in pregnant women for induction of labor or abortion

Dear Health Care Provider: The purpose of this letter is to remind you that Cytotec administration by

any route is contraindicated in women who are pregnant because it can cause abortion. Cytotec is not approved for the induction of labor or abortion.

Cytotec is indicated for the prevention of NSAID (nonsteroidal anti-inflammatory drugs, including aspirin)-induced gastric ulcers in patients at high risk of complications from gastric ulcer, e.g., the elderly and patients with concomitant debilitating disease, as well as patients at high risk of developing gastric ulceration, such as patients with a history of ulcer.

The uterotonic effect of Cytotec is an inherent property of prostaglandin E1(PGE1), of which Cytotec is stable, orally active, synthetic analog. Searle has become aware of some instances where Cytotec, outside of its approved indication, was used as a cervical ripening agent prior to termination of pregnancy, or for induction of labor, in spite of the specific contraindications to its use during pregnancy.

Serious adverse events reported following off-label use of Cytotec in pregnant women include maternal or fetal death; uterine hyperstimulation, rupture or perforation requiring uterine surgical repair, hysterectomy or salpingo-oophorectomy; amniotic fluid embolism; severe vaginal bleeding, retained placenta, shock, fetal bradycardia and pelvic pain.

Searle has not conducted research concerning the use of Cytotec for cervical ripening prior to termination of pregnancy or for induction of labor, nor does Searle intend to study or support these uses. Therefore, Searle is unable to provide complete risk information for Cytotec when it is used for such purposes. In addition to the known and unknown acute risks to the mother and fetus, the effect of Cytotec on the later growth, development and functional maturation of the child when Cytotec is used for induction of labor or cervical ripening has not been established

Searle promotes the use of Cytotec only for its approved indication. Further information may be obtained by calling 1-800-323-4204.

Michael Cullen, MDMedical Director, U.S.Searle

Hydramnios

• Polyhydramnios

• Over 2000mL of amniotic fluid

• Often occurs in cases of major congenital anomalies, malformations that affect swallowing, anencephaly

• Diabetes, Rh sensitization, infections (syphilis, toxoplasmosis, cytomegalovirus, herpes, rubella)

Oligohydramnios

• Largest pocket of amniotic fluid is 5 cm or less on ultrasound

• Postmaturity, IUGR, renal malformations in the fetus

CPD

• Cephalopelvic Disproportion

• Contracture of the bony pelvis or the maternal soft tissues

• Contractures of the inlet, outlet, midpelvis

• Labor is prolonged and protracted

Retained Placenta

• Retention of the placenta beyond 30 minutes after birth of the baby

• Manual removal

Lacerations

• Bright red bleeding: cx, vagina

• Risks: nullip, epidural, forcps, VAD, epis1. First–degree: limited to fourchette, perineal skin and

vaginal mucous membrane

2. Second-degree: perineal skin, vaginal mucous membrane, fascia, muscles of the perineal body

3. Third-degree: involves anal sphincter and may extend up the anterior wall of the rectum

4. Fourth-degree: extends thru the rectal mucosa to the lumen of the rectum.

Placenta Accreta

• Chorionic villi attach directly to the myometrium of the uterus

• Increta: myometrium is invaded

• Percreta: myometrium is penetrated

• Causes maternal hemorrhage

• Tx may be abdominal hysterectomy