ICEA Study Guide 9 – Complications, Interventions & Unexpected Outcomes

OBJECTIVES At the completion of Part 9 the learner will:

  • define common diagnostic tests used during pregnancy.
  • list several complications of pregnancy.
  • list possible complications of labor and the interventions, in their community and country of 
practice that may result.
  • list possible fears experienced during the childbearing year.
  • list benefits and risks of cesarean birth and common associated procedures.
  • define the acronym VBAC (vagina birth after cesarean).
  • analyze personal and societal issues that influence perinatal loss.
  • identify steps of the grief process.

 

OUTLINE

  1. Diagnostic testing in pregnancy
  2. Glucose tolerance test (GTT)

Routine Exams and Screening Tests

Every visit

  • Urine test to detect bacteria, protein and sugar (at first visit, urine test can confirm pregnancy)
  • Blood pressure check to screen for high blood pressure
  • Weight check to monitor nutritional status and detect sudden weight gain (which can indicate preeclampsia)
  • Abdominal exam – to measure uterine growth or fundal height (which indicates baby’s growth) and estimate baby’s position
  • Fetal heart tones – listen to confirm baby’s well being

Specific Visits

  • Pelvic exam – confirm pregnancy, estimate size of mother’s pelvis, check for infection or perform Pap smear. In late pregnancy, reveals cervical changes
  • Blood test – at first visit to confirm pregnancy, determine blood type, test for anemia, and assess exposure to infection. For women with diabetes, caregivers check blood glucose levels periodically throughout pregnancy
  • Breast exam – screen for breast cancer and assess for conditions affecting breastfeeding

See PCN Guide

Other Exams/Screening

  • Dental – by dentist to check for tooth decay; check for gum infection which is associated with preterm labor
  • Fetal movement counts (kick counts) – done by you
  • Ultrasound – confirm pregnancy, estimate due date and baby’s size, detect/rule out complications
  • Integrated prenatal screening – assess risk of down syndrome and neural tube defects such as spina bifida. Combination of first trimester screening tests (ultrasound and blood tests) and second trimester blood tests. If results outside range, diagnostic test.
  • Genetic screening – checks for cystic fibrosis, tay-sachs, thalassemia and sickle cell anemia. If blood/saliva tests reveal risk, recommend diagnostic tests.
  • Glucose screening – detect high glucose levels, which may indicate gestational diabetes between 24th and 28th After sugary drink, blood is drawn. If blood sugar high, recommend glucose tolerance test
  • Group B streptococcus (GBS) screening – presence of GBS bacteria in secretions swabbed from vagina and anus and cultured in lab

Understanding Ultrasound – 2 forms: Doppler and diagnostic scan. Doppler monitors baby’s heart rate, uses continuous transmission of sound waves to detect motion of baby’s heart as it beats. Done via hand-held device. Scan helps “see” inside uterus, ising intermittent transmission of sound waves for less than 1% of the time during the test. For the rest of the test, the equipment receives the echoes of the sound waves, which indicate differences in tissue density. See PCN guide 

Studies found no evidence that they harm mother or baby and that benefits outweigh risks. Estimating baby’s age and weight more reliable in early pregnancy. First sight of babies inspires many parents to make an effort to heave a healthy pregnancy and birth.

Warning Signs of Pregnancy Complications:

  • Vaginal bleeding – miscarriage, placenta previa, placenta abruption, preterm labor
  • Abdominal Pain – ectopic pregnancy, miscarriage, placental abruption, preterm labor contractions. May indicated medical problem such as appendicitis or gallbladder disease
  • Continuing, intermittent abdominal cramping or uterine tightening (contractions) – preterm labor
  • Constant and severe abdominal pain and a hard abdomen, with or without vaginal bleeding – placental abruption
  • Leaking or gushing of fluid from vagina – rupture of membranes
  • Sudden puffiness or welling of face, hands or fingers – preeclampsia
  • Severe, persistent headache – gestational hypertension or preeclampsia
  • Problems with vision (seeing spots or flashes, blurring or blind spots) – preeclampsia
  • Severe and persistent dizziness, lightheadedness – preeclampsia; supine hypotension
  • Noticeable reduction or change in baby’s movement or activity after 28th week of pregnancy – fetal distress
  • Painful area in leg, swelling or redness over affected area, or pain in leg when standing/walking – blood clot in leg or inflammation of vein (venous thrombosis)
  • Severe pain in pubic area and hips, with trouble moving yoru legs – strain or separation of pubic symphysis joint or sciatica (pain in lower back from pelvic joint stress)
  • Painful urination or burning sensation, with or without the urgent and frequent need to urinate – UTI or STI
  • Irritating vaginal discharge, genital sores or vaginal itching – vaginal infection or STI
  • Fever (temp over 102) when feeling sick – infection
  • Persistent nausea/vomiting – hyperemesis gravidarum; infection

Fetal Movement Counting – some caregivers ask only those women with high-risk pregnancies to count their babies’ movements. Baby doing well in uterus have several active, wakeful periods during the day. Healthy babies move slightly less often toward end of pregnancy due to space restrictions within uterus but don’t markedly reduce activity unless there is a problem. If baby becomes noticeable less active, call caregiver.

The Count to Ten Method – after 28th week, count baby’s movements each day at roughly same time. PCNguide has template. Length of time it takes to complete 10 movements varies among babies. Focus not on how baby’s movements compare with other babies’ but on whether his activity has slowed down compared to his usual pattern. Try waking baby up with a loud noise or wait until you feel baby move. Call caregiver if it takes a longer time than usual to make 10 movements or if baby doesn’t move at least 10x or have an active period within the next 12 hours.

 

Screening for Gestation Diabetes Mellitus – all women not known to have pregestational diabetes should be screened for GDM by history, clinical risk factors of lab screening of blood glucose levels. Glucose testing for low risk may not be cost effective (normal weight women <25 years who have no family history of diabetes, not members of ethnic or racia group known to have high prevalence, no history of abnormal glucose tolerance or adverse obstetric outcomes associated w GDM; however only 10% of women meet this criteria).

2 different blood glucose screening methods used in U.S. ACOG recommends 2 step screening method. 1st step is screen consisting of 50 g oral glucose load followed by plasma glucose measurement 1 hr later. Woman does not need to fast. Glucose value of 130-140 mg/dl considered positive screen. Initial positive screening result followed by step 2, 4 hr 100 g oral glucose tolerance test (OGTT) on another day. ACIG recommends because no evidence that 1 step method leads to clinically significant improvement in maternal or newborn outcomes. Use of 1 step does significantly y increase health care costs because more women will be diagnosed w GDM and will require more visits, tests and procedures than pregnant women who do not have this disease.

OGTT administered after overnight fast and at least 3 day s of unrestricted diet (at least 150 g of carbs) and physical activity. Woman instructed to avoid caffeine because it increases glucose levels and to abstain from smoking for 12 hrs before test. 3 hr OGTT requires fasting blood glucose level, drawn before giving 100 glucose load. Blood glucose levels are drawn 1,2,and 3 hrs later. Woman diagnosed w GDM if 2+ values met or exceeded. 2 different sets of glucose values are commonly used to diagnose following 100g OGTT. At this time, use of 1 set of glucose values cannot be clearly recommended over other. Providers urged to select one set of values and use consistently with practice.

International Association of Diabetes and Pregnancy Study Groups recommends 1 step method of screening and diagnosis. Increasing rates of obesity and diabetes have resulted in more women of childbearing age w type 2 diabetes, many of whom are undiagnosed when they become pregnant. IADPSG recommends that high risk women be tested for over diabetes at initial prenatal visit using standard criteria. If tests done early in pregnancy for overt diabetes are normal, a 75 g OGTT diagnostic test is administered between 24 and 28 weeks. 75 g OGTT requires a fasting blood glucose level, which is drawn before giving glucose load. Blood glucose levels then drawn 1 and 2 hrs later. Diagnose of GDM made if only 1 value exceeded. 1 step method significantly increases incidence of GDM. ACOG does not recommend this method.

Nursing diagnoses and expected outcomes for women with GDM basically same as those for women with pregestational diabetes except that time frame for planning may be shortened since diagnosis made later in pregnancy.

 

Step 1: 1 hr 50 g oral glucose screen -> negative (<130-140 mg/dl) -> routine prenatal care

  • Positive (>130-140 mg/dl) -> Step 2: 3 hr 100 g oral glucose tolerance test (OGTT) -> positive for GDM if 2+ values met/exceeded: fasting 95 mg/dl or 105 mg/dl; 1 hr 180 mg/dl OR 190 mg/dl; 2 hr 155 mg/dl OR 165 mg/dl; 3 hr 140 mg/dl OR 145 mg/dl

Evidence Based Practice: Debating Gestation Diabetes Diagnosis: For pregnant women with hyperglycemia, at what level do diagnosis and treatment for gestational diabetes become most beneficial for baby?

High serum glucose in pregnancy associated with complications such as preeclampsia, macrosomia, operative vaginal birth, shoulder dystocia, birth injury, cesarean birth, neonatal hypoglycemia, need for NICU, respiratory distress and jaundice. Commonly accepted method of diagnosing has been nonfasting glucose challenge at 24-28 weeks. for 50 g glucose challenge test, most common cutoff was 140 mg/dl, a level that was associated with macrosomia and gestation hypertension. Elevated result triggered a fasting 2 or 3 hr OGTT. 2nd abnormal resulted in diagnosis of GDM. Using this approach, about 5-6% of pregnant women received treatment, including diet, exercise, glucose monitoring and possibly metformin.

IADPSG approach identifies GDM in ~18% of all pregnant women. Criticism of 1 step approach includes reliance on just 1 abnormal result an unintended consequences of labeling woman w GDM: increase in cesarean and possibly labor induction, additional fetal assessments, more intensive newborn assessments, significantly increased client costs, life disruptions and psychological stress. 2 step approach recommended.

 

2 hr 75 OGTT – > positive (1 value met/exceeded): fasting 92 mg/dl; 1 hr 180 mg/dl; 2 hr 153 mg/dl

Interventions:

  • Antepartum: when diagnosis of GDM is made, treatment begins immediately, allowing little or no time for woman and family to adjust to diagnosis. Potential complications should be discussed and need for maintaining euglycemia throughout remainder of pregnancy reinforced. Knowing that GDM typically disappears when pregnancy is over is reassuring. Aim of therapy is strict blood glucose control. Fasting levels should range from 60-99 mg/dl and 1 hr postprandial values bw 100-129 mg/dl. Postmeal levels at 2 hrs should be no higher than 120 mg/dl.
  • Diet: mainstay of treatment. Placed on standard diet for women with diabetes. 30 kcal/kg/day based on normal preconception weight. For obese women, 25 kcal/kg/day, which translates into 1500-2000 kcal/day. Carb intake restricted to 50% of caloric intake. Dietary counseling by registered dietitian recommended
  • Exercise: few published studies on benefits of exercise in women with GDM. In adults who aren’t pregnant, exercise increases lean muscle mass and improves sensitivity to insulin. Moderate exercise program recommended for overweight or obese women with GDM in order to improve blood sugar control and facilitate weight loss
  • Self-Monitoring of Blood Glucose– necessary to determine whether euglycemia can be maintained by diet and exercise. Women instructed to monitor blood sugar daily. Frequency and timing should be individualized for each woman. Typical schedule is upon rising in AM, 1-2 hrs after breakfast, before and after lunch, before dinner and at bedtime. Women perform at home and review at prenatal visits to determine effectiveness of diet/exercise. If glycemic thresholds not met, then pharmacologic intervention.
  • Pharmacologic Therapy – ~ 25% of women require insulin to maintain levels, despite compliance with prescribed diet. In contrast to women w insulin-dependent diabetes, women w GDM managed initially w diet and exercise alone. If fasting plasma glucose levels persistently >95 mg/dl, 1 hr postmeal levels persistently greater than 140 mg/dl or 2 hr postmeal levels persistently > 120 mg/dl, insulin therapy is begun.
    • For past several years, oral hypoglycemic therapy has been used as alternative to insulin in women w GDM who require medication in addition to diet for blood glucose control. Women unable/unwilling to take insulin by injection or are cognitively impaired may also be candidates
    • Glyburide is oral agent most frequently prescribed. Only minimal amounts of glyburide cross placenta to fetus. Research revealed no increase in hypoglycemia or macrosomia in neonates, though in 1 study found more likely to experience birth injury or require phototherapy. May not work as well in obese women or who experienced higher levels of hyperglycemia early in pregnancy. Should be taken at least 30 min (preferable 1 hr) before meal so its peak effect covers glycemia that can occur between meals; women should always carry glucose meter with them, along with glucose tablets or gel.
    • Metformin is another oral hypoglycemic agent sometimes used. It crosses placenta but does not appear to be teratogenic. Glyburide may be better than metformin at controlling blood glucose levels because it causes maternal pancreas to produce more insulin, whereas metformin decreases hepatic glucose production and increases peripheral sensitivity to insulin.
  • Fetal Surveillance – women w GDM whose blood glucose levels are well controlled by diet are at low risk for an IUFD. Therefore, antepartum fetal testing is not performed routinely in these women unless they also have hypertension, a history of prior stillbirth, or suspected macrosomia. Women with these complications or those who require insulin for blood glucose control may have 2x weekly NSTs beginning at 32 weeks. Women w uncomplicated GDM begin fetal testing at 40 weeks gestation. Women w well-controlled GDM can continue pregnancy until 40 weeks and spontaneous onset of labor. Fetal growth should be monitored carefully because risk for macrosomia as pregnancy approaches 40 weeks is increased
  • Intrapartum – during labor and birth, blood glucose levels monitored hourly to maintain levels at 80-111 mg/dl. Levels within range decrease incidence of neonatal hypoglycemia. Infusing rapid-acting insulin intravenously may be necessary during labor to maintain desired blood glucose levels. Usually possible to maintain excellent glucose control in women w GDM during labor by avoiding use of IV fluids containing dextrose. If glucose-containing solutions are given, should be administered by an infusion device so that inadvertent boluses are avoided. Although not an indication for cesarean, this procedure may be necessary in presence of preeclampsia or macrosomia.
  • Postpartum – most women w GDM return to normal glucose levels after childbirth, up to 1/3 will have diabetes or impaired glucose metabolism when screen postpartum. 15%-5-% will develops type 2 diabetes later in life. ACOG recommends assessing all women who had GDM for carb intolerance w a 75 g 2 hr OGTT of fasting plasma glucose level at 6-12 weeks postpartum. Optimal frequency of subsequent testing has not been established. ADA recommends repeat testing every 3 years and normal postpartum glucose testing results. Obesity is a major risk factor for later development of diabetes. Women w history of GDM, particularly those overweight, should be encouraged to make lifestyle changes that include weight loss and exercise to reduce this risk for becoming obese in childhood or adolescence.
    • Low dose oral contraceptives may be safely used by women w history of GDM. Rate of subsequent diabetes is no different from those without history who use low dose oral contraceptives. Women also obese or have hypertension or high lipid levels in addition to a history of GDM should use a contraceptive method without potential for causing cardiovascular side effects. For these women, IUD is a good option.

Hyperemesis Gravidarum – nausea and vomiting complicate 50-80% of all pregnancies, typically beginning at 4-10 weeks. Symptoms usually confined to first 20 weeks. Although distressing, typically benign w no significant metabolic alterations or risks to mom/fetus.

Cause not well known, although may involve relaxation of smooth muscle of stomach and increasing levels of estrogen and hCG. Gastric dysrhythmias, reduced gastric motility and gastroesophageal reflux may also contribute. Some suggested they are evolutionary adaptations in order to protect woman and fetus from potentially harmful foods. Pregnancies generally have a more favorable outcomes that those without they symptoms.

When vomiting becomes excessive enough to cause weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria, its termed hyperemesis. Occurs in approx. .5% of all live births. Usually begins during 1st trimester, but approx. 10% of women w disorder continue to have symptoms throughout pregnancy. 2nd most common reason for hospitalization during pregnancy in U.S.

Risk factors include clinical hyperthyroid disorders, prepregnancy psychiatric diagnosis, previous pregnancy complicated by HG, molar pregnancy, multiple gestation w male and female fetus, diabetes and gastrointestinal disorders. Women carrying female fetus more likely to develop. Family history may also be present. Women age 30+ who smoke have a lower risk.

Severe but rare maternal complications include esophageal rupture, pneumomediastinum and deficiencies of Vit K and thiamine w resulting Wernicks encephalopathy.

Infants born to women who had poor pregnancy weight gain may be small for gestational age, have a low birth weight, or be born prematurely. May also have 5 min Apgar scores less than 7.

Etiology – psychosocial, cultural and psychogenic, as well as physiologic factors may play a part for some reason. Conflicting feelings regarding prospective motherhood, body changes and lifestyle alterations may contribute to episodes of vomiting, particularly if feelings are excessive or unresolved. Women w associated psychosocial factors usually improve dramatically while in hospital but may resume vomiting after discharge.

Clinical Manifestations – usually has significant weight loss and dehydration. She may have dry mucous membranes, decreased BP, increased pulse rate, and poor skin turgor. Frequently she is unable to keep down even clear liquids taken by mouth. Lab test may reveal electrolyte imbalance.

  1. Amniocentesis

 

Diagnostic Tests

Results from 1 test might not be completely accurate, so caregiver may order several to confirm diagnosis; some have more risks than others.

Tests to detect genetic defects and diseases – you may choose not to have these invasive tests because they require penetrating uterus. Although rare, potential risks include miscarriage, infection, bleeding or leaking of amniotic fluid.

  • Amniocentesis – between 15th and 20th week of pregnancy, lab test can sample amniotic fluid to detect Down syndrome, sickle cell anemia, neural tube defects and other disorders. Results available in 2 weeks. May use amniocentesis in late pregnancy to assess baby’s lung maturity before a preterm birth
  • Chorionic villus sampling (CVS) – examines small piece from chorionic villi (early placenta) to provide info about chromosomal abnormalities in baby between 10th and 12th week
  • Cordocentesis or percutaneous umbilical blood sampling (PUBS) – sample of baby’s blood from umbilical cord to detect chromosomal defects, blood disorders, and conditions such as infection, anemia and lack of oxygen. Done after 18th week of pregnancy. Because test carries more risks than amniocentesis, only used when need confirmation of diagnosis more quickly.

 

Biochemical Assessment – biologic exam (ex of chromosomes in exfoliated cells) and chemical determinations (ex lecithin/sphingomyelin L/S ration, or phosphatidylglycerol (PG). procedures used to obtain needed specimens include amniocentesis, percutaneous umbilical blood sampling, chorionic villus sampling and maternal sampling.

 

 Summary of Biochemical Monitoring Techniques

Test/Possible Findings/Clinical Significance

Maternal Blood

  • Coombs test – titer of 1:8 and increasing/ significant Rh incompatibility
  • Cell-free DNA screening – > normal amt of DNA from specific chromosomes/ fetus w trisomy 13, 18 or 21
  • AFP – see AFP later in table

Amniotic Fluid Analysis

  • Lung profile: fetal lung maturity
    • L/S ratio – 2:1/
    • Phosphatidylglyerol: present
    • LBC: >50k/uL
  • Creatinine- >2mg/dl; gestation age >36 wks
  • Lipid cells- >10%; gestational age >35 wks
  • AFP- high levels after 15 wks gestation/ open neural tube or other defect
  • Osmolality- declines after 20 wks gestation/ advancing gestational age
  • Genetic Disorders (sex-linked, chromosomal, metabolic)– dependent on cultured cells for karyotype and enzymatic activity/ counseling possible required

 

Fetal rights – amniocentesis, percutaneous umbilical cord sampling (PUBS), and chorionic villus sampling (CVS) are prenatal tests used for detecting fetal defects. They are invasive and carry risks to mom and fetus. Consideration of induced abortion linked to tests because no treatment for genetically affected fetuses has been developed; therefore issue of fetal rights is a key ethical concern.

Amniocentesis – performed to obtain amniotic fluid, which contains fetal cells. Under direct ultrasonographic visualization, a needles in inserted transabdominally into uterus, amniotic fluid is withdrawn into a syringe and various assessments are performed. Possible after week 14, when uterus becomes an abdominal organ and sufficient amniotic fluid is available for testing. Indications for procedure include prenatal diagnosis of genetic disorders or congenital anomalies (NTDs in particular), assessment of pulmonary maturity, and (rarely) diagnosis of fetal hemolytic disease.

Complications in mom/fetus occur in less than 1% of cases and include:

  • Maternal: leakage of amniotic fluid, hemorrhage, fetomaternal hemorrhage w possible maternal Rh isoimmunication, infection, labor, placental abruption, inadvertent damage to intestines or bladder, and amniotic fluid embolism (anaphylactoid syndrome of pregnancy)
  • Fetal – death, hemorrhage, infection (Amnionitis) and direct injury from needle

Many of complications have been minimized or eliminated by using ultrasonography to direct the procedure.

Because of possibility of fetomaternal hemorrhage, administering Rh0D immune globulin to woman who is Rh negative is standard practice after amniocentesis.

Indications for Use:

  • Genetic Concerns – historically prenatal assessment of genetic disorders focused on women >35, women w previous child w chromosomal abnormality or family history. Inherited errors of metabolism (Tay-Sachs), hemophilia, thalassemia, and other disorders for which marker genes are known also can be detected by prenatal screening. Fetal cells can be cultured for karyotyping of chromosomes; it also permits determination of fetal gender, which is important if X-linked disorder (occurring almost always in male fetus) is suspected.
    • Biochemical analysis of enzymes in amniotic fluid can detect inborn errors of metabolism or fetal structural anomalies. Ex: Alpha-fetoprotein (AFP) levels in amniotic fluid are assessed as a follow-up for elevated levels in maternal serum. High aFP levels in amniotic fluid help confirm diagnosis of an NTD such as spina bifida or anencephaly or an abdominal wall defect such as omphalocele. The elevation results form the increased leakage of cerebrospinal or abdominal fluid into the amniotic fluid through the closure defect.
  • Fetal Maturity – late in pregnancy accurate assessment of fetal lung maturity is possible by examining amniotic fluid to determine L/S ratio or for presence of PG. because both tests require considerable time, technical expertise, and cost to perform, they are generally used as primary tests only in special clinical circumstances . may also be used as secondary tests if simpler and less expensive automated tests indicate lung immaturity.
    • Until recently the TDx FLM assay and a subsequent modification, the TDx FLM II assay, were used as primary tests for fetal lung maturity. These assays determined the surfactant-to-albumin (S/A) ratio. However, they are no longer available for use in U.S. instead lamellar body count (LBC) has become primary test for determining fetal lung maturity.
    • Lamellar bodies are surfactant-containing particles secreted by type II pneumocytes. # of bodies found in amniotic fluid increases w onset of functional fetal L/S ratio and PG test in predicting fetal lung maturity. The automated test is simple to perform and almost all hospital labs have equipment use to perform it.
  • Fetal Hemolytic Disease– in past, amniocentesis was used for ID and follow-up of fetal hemolytic disease in cases of isoimmunization. Amniocentesis is now performed for this reason only in rare circumstances because of availability of noninvasive testing. Doppler velocimetry of fetal middle cerebral artery has become the method of choice to monitor accurately and noninvasively for fetal anemia in isoimmunized pregnancies.

 

  1. Chorionic villus sampling

Chorionic Villus Sampling – combined advantages of earlier diagnosis and rapid results have made CVS a popular technique for genetic studies in 1st trimester. Indications similar to those for amniocentesis, although CVS cannot be used for maternal serum marker screening because no fluid is obtained. CVS performed in 2nd trimester carries no greater risk of pregnancy loss than amniocentesis and is considered equal in diagnostic accuracy. When performed after 1st trimester, procedure known as late CVS or placental biopsy.

CVS can be performed in 1st or 2nd trimester, ideally bw 10-13 weeks and involves removal of small tissue specimen from fetal portion of placenta. Because chorionic villi originate in zygote, this tissue reflects the genetic makeup of fetus.

CVS procedures can be accomplished transcervically or transabdominally. In transcervical sampling a sterile catheter is introduced into the cervix under continuous ultrasonographic guidance, and a small portion of the chorionic villi is aspirated wit ha syringe. The aspiration cannula and obturator must be placed at a suitable site, and rupture of amniotic sac must be avoided. The transcervical procedure is contraindicated in a cervical infection such as chlamydia or herpes is present.

If abdominal approach is used, an 18 or 20 gauge spinal needle w stylet is inserted under sterile conditions through the abdominal wall into the chorion frondosum under ultrasound guidance. Stylet is then withdrawn, and chorionic tissues is aspirated into a syringe.

CVS is a relatively safe procedure. Incidence of IUGR, placenta abruption and preterm birth is no higher in women. In early 1990s, there was controversy regarding increased risk for fetal limb reduction defects associated w CVS. However, consensus of further studies is that when CVS is performed after 9 completed weeks, risk for limb reduction defects is no higher than in general population.

Use of amniocentesis and CVS is declining because of advances in noninvasive screening techniques: measurement of NT, maternal serum screening tests in 1st and 2nd trimesters and ultraonography in 2nd trimester. Recently available assessment method, cell-free deoxyribonucleic acid (DNA) screening, can be performed as early as 10 weeks to aid in decision making regarding further testing.

Because of possibility of fetomaternal hemorrhage, women Rh negative should receive Rh0D immune globulin after CVS to prevent isoimmunciation, regardless of whether procedure is performed transcervically or transabdominally, unless fetus is known to be Rh negative.

Elimination of Maternal Age as an Indication for Invasive Prenatal Diagnosis – age 35+ has been standard indication for invasive prenatal testing since 1979. However, because most genetically abnormal children are born to parents of varying ages who have no history of abnormality, genetic screening is now recommended for all women, regardless of age. ACOG states no specific age should be used as threshold for invasive or noninvasive screen. All women, regardless of age should have option of invasive testing w out first having screening.

 

 

  1. 
Percutaneous umbilical blood sampling (PUBS)

Percutaneous Umbilical Blood Sampling – direct access to fetal circulation during 2nd and 3rd trimesters is possible through PUBS (also called cordocentesis). Can be used for fetal blood sampling and transfusion. Has been replaced in many centers by placental biopsy because is is a safer, easier and faster alternative. Improvements in cytogenetic and molecular diagnostic testing have decreased the need for fetal blood samples. Many tests that were once performed using fetal blood can now be done using DNA-based analysis of chorionic villi.

 

PUBS involves the insertion of needle directly into fetal umbilical vessel, preferably the vein, under ultrasound guidance. Ideally the umbilical cord is punctured near its insertion into the placenta. At this point the cord is well anchored and will not move, and the risk of maternal blood contamination (from placenta) is slight. Generally a small amount of blood is removed and tested immediately by the Kleihauer-Betke procedure (Apt test) to ensure that it is fetal in origin. The most common genetic indication for use of PUBS is evaluation of mosaic results found on amniocentesis of CVS, when a sample of fetal blood is required to determine the specific mutation. PUBS is also used to assess for fetal anemia, infection, and thrombocytopenia. Complications that can occur include loss of pregnancy, hematomas, bleeding from puncture site in umbilical cord, transient fetal bradycardia, and fetomaternal hemorrhage. Maternal complications are rare but include hemorrhage and transplacental hemorrhage.

In fetuses at risk for isoimmune hemolytic anemia, PUBS permits precise identification of fetal blood type and RBC count and may prevent the need for further intervention. If fetus is positive for presence of maternal antibodies, a direct blood test can confirm the degree of anemia resulting from hemolysis. Intrauterine transfusion of severely anemic fetuses can be performed 4-5 weeks earlier than through the intraperiotoneal route.

Follow-up includes continuous FHR monitoring for 1-2 hrs after procedure. Women should also be taught to count fetal movements at home.

 

Imaging Tests for Your Health and Baby’s Well Being – noninvasive look at baby and uterine structures, except for x-ray, they pose no significant risks

  • Ultrasound – helps estimate baby’s gestational age and maturity, locates her organs and structures and detects her presentation and position in the uterus. Can determine preterm cervical changes and assess amniotic fluid volume. Often used in conjunction with external version of breech baby, CVS and amniocentesis.
  • Magnetic resonance imaging (MRI) – visual images of internal structure of baby can help confirm malformations. Assess internal organs for potential complications. May use when results of ultrasound unclear.
  • Doppler arterial blood flow studies (velocimetry) – circulation of blood within and among uterus, placenta and your baby. can see if baby is at risk for blood flow complications such as intrauterine growth restriction (IUGR), anemia and prematurity form severe preeclampsia.
  • X-ray – rarely used but can help diagnose pneumonia, dental disease and broken bones

Tests for Baby’s Well-being in late pregnancy

  • Non-stress test (NST) – monitor baby’s heart rate when he’s actively moving, can determine well being and whether a high risk pregnancy can continue
  • Biophysical profile (BPP)- considers info from NST and uses ultrasound to evaluate amniotic fluid volume and baby’s functions. Can assess if high risk or post date pregnancy can safely continue or if induction should be considered. Because test monitors 5 factors (But not baby’s size), it’s a fairly good indicator of condition
  • Contraction stress test (CST) or oxytocin challenge test (OCT) – caregiver induces contractions and monitors baby’s heart rate to predict when he can withstand stress of labor contractions. If not, cesarean may be necessary. Not usually done unless NST indicates problem

 

Predictability in Parturition – scheduled labor, scheduled feeds for infants and scheduled times for affection are counterproductive to developing a mentally, physically and emotionally healthy child who gives joy to his or her family and matures into a productive, capable, engaging adult. The devastatingly negative effect of scheduled feeds on breastfeeding is well documented.

Estrogens used to induce labor have been shown to have a strong inhibitory influence on lactogenesis.

Oxytocin in form of Pitocin delivered intravenously is a common method of labor induction. It is centrally involved in far more than uterine contractions and milk release: it is the hormone of calm and connection, counterbalancing the fight or flight states related to elevated adrenalin. Basal oxytocin levels in mom are positively correlated to affectionate and attentive maternal behavior; milk production, release and consumption by the baby; digestion in mom and infant; visual memory of faces; and healing and restoration of somatic systems. Without normal pulsatile oxytocin responses, the mother’s milk synthesis and its release to the infant is compromised, which quickly undermines breastfeeding.

There is evidence that oxytocin administered to induce or augment labor has a negative effect on endogenous oxytocin and patterns of oxytocin release (pulsatile or nonpulsatile) in the postpartum period. When labor is induced, contractions are stronger, closer and more painful; women often request epidural or other narcotic pain relief. Epidural anesthesia coupled with IV oxytocin is increasingly associated with fetal stress and breastfeeding difficulties. Oxytocin infusion decreased endogenous oxytocin levels dose-dependently. Oxytocin infusion facilitated the release of prolactin. Epidural analgesia in combination with oxytocin infusion influenced endogenous oxytocin levels negatively.

Elective inductions for Primigravidas increase cesarean rate by 2-4x.

 

  1. Imaging

Cascade of Interventions: Chance or Choice? The “Seduction of Induction”- maturation of baby is a major factor determining onset of labor. Normal pregnancy avg 40-41 weeks, with greatest # of births occurring spontaneously between 38-42 weeks. Babies born at less than 38 or more than 42 more likely to experience complications. As baby matures and develops in utero, its hypothalamic-pituitary-adrenal axis is activated causing the release of fetal cortisol, which in turn stimulates the placenta to release corticotropin-releasing hormone (CRH), a hormone that has many actions on the fetal membranes and maternal cervix.   The mother’s pituitary responds to CHR by releasing adrenocorticotropic hormone (ACTH), which stimulates her adrenal glands to release cortisol. Maternal adrenal cortisol prepares the uterus for labor, making it more sensitive to oxytocin. The placenta begins to convert progesterone to estrogen. It needs androgens from maternal and fetal adrenals to do this. Estrogen increases the oxytocin receptors in the uterine lining by 100-200x. the uterus becomes even more sensitive to oxytocin, which triggers gradually more frequent and stronger contractions of the muscle fibers. Contractions act both on the uterus and the infant/fetus, massaging the baby, which helps mature the lungs and produces beta-endorphins (natural pain-relieving, opiate-like substances) to protect the baby during mechanical passage of labor and birth. The hypothalamus-pituitary axis increases production of oxytocin, the powerful bio and psychoactive hormone that helps prepare mom and baby for their mutual caregiving roles after birth. Estrogen also triggers the production of prostaglandins in the uterus, membranes and placenta, which stimulate contractions and soften the cervix. Estrogen also improves the mother’s clotting ability to protect against hemorrhage.

Simultaneously with the hormonal influences on the uterus, the decreasing levels of progesterone signal the lactocytes in the breast to begin their transition from lactogenesis I into lactogenesis II; a sharp rise in lactose synthesis signals the beginning of lactogenesis II (onset of copious milk secretion). Thus, as the baby readies for life outside the womb, the mother’s body prepares her for labor, birth, lactation and a breastfeeding relationship with her baby.

 

  1. Tests for fetal well-being

Tests to Detect Potential Pregnancy Problems

  • Glucose tolerance test (GTT) – first have blood drawn, then drink sugary drink and have blood drawn again every hour in 3 hour period
  • Vaginal or cervical smear – obtains secretions from vagina or cervical area to defect infectious organisms, premature rupture of membranes or substances that indicate an increased risk of preterm labor

Key Points

  • Most pregnancies don’t develop complications and both mother and baby are healthy at birth and afterward
  • Can decrease chances of developing serious problems form chronic condition or from complication that arises with appropriate prenatal care
  • Promptly contact caregiver if see warning signs of complications; early treatment helps minimize severity of complications
  • http://www.pcnguide.com/wp-content/uploads/2016/03/2-Diagnostic-Tests.pdf

 

  1. Pregnancy Complications
  2. Abuse and domestic violence

Special Challenges in Pregnancy – past traumatic experiences can present additional challenges

  • History of Childhood Trauma – early childhood trauma sometimes causes unexpected reactions during pregnancy, birth or afterward. Women physically, sexually or emotionally abused as adults can also experience these reactions. Many abused women have difficulty trusting others, especially those in authority (such as physicians or midwives).
    • Estimated that 25-40% of women were sexually, physically or emotionally abused in childhood.
    • Survivor may find vaginal exams, nakedness or prospect of a baby coming through her vagina extremely disturbing or even intolerable
    • May respond to inevitable loss of control over body that occurs in labor in same way she had as a child, when she was helpless to stop her abuser from hurting her
    • May equate though of giving another person total access to her breast, even for breastfeeding, to her inability to prevent her abuser’s violation of her body
    • Extent of these problems vary and may factors influence including nature of abuse, age at which it occurred, how long it lasted, presence or absence of other loving and trustworthy adults in her life. Psychotherapy and emotional support groups promote healing. Appendix C for list of resources for survivors of childhood abuse.
  • Pregnancy After Miscarriage or Stillbirth – knowing why a previous pregnancy ended may help you and caregiver plan. Offer more prenatal testing. Closely watch baby’s health by counting movements. Talk with family members, friends, grief counselors and medical professionals.
    • Books: Pregnancy after a Loss; Trying Again: A guide to pregnancy after miscarriage, still birth and infant loss
  • Disability – consult with physical or occupational therapist or with women you’re your disability who have managed a pregnancy and parenting. Search for online discussion forums

Key Points: 1st trimester – formation period; 2nd trimester – development period; 3rd trimester is growth period

 

What Causes Chronic Stress? Any situation or event that upsets you can cause chronic stress if left unmanaged. Examples include demanding job, financial worries, unstable home life, problems with partner, loved one’s illness or violence or danger in life. May have an extreme reaction to everyday pressures because of unresolved or untreated anxiety from a pervious traumatic event (including emotional, physical or sexual abuse), a chemical imbalance that causes your brain to interpret minor stresses as major ones, or hormonal changes.

Coping with Chronic Stress –

  • Recognize stress response. Notice how you feel when anxious/stressed (overwhelmed, trouble sleeping, headaches, bowel problems etc)
  • Identify source – which person, situation or experience triggers
  • Try to eliminate source – transfer/quit stressful job, leave abusive home
  • Learn better ways to cope
    1. Stay away from people who trigger a stress response
    2. Get enough sleep and nap during day; fatigue makes everything worse
    3. Relaxation skills on pg 216-220. Slow breathing while resting, meditating or listening to soothing music
    4. Nourishing foods and drink plenty of water and other fluids
    5. Exercise regularly
    6. Discuss problems
    7. Nurture yourself – massage, manicure or facial. Take a walk through park. Spend time with people who comfort you

 

Substances and Hazards to Avoid during Pregnancy – everything affects baby from caffeinated coffee and herbal teas to dangerous situations such as abuse and domestic violence. Depends on amount and frequency of exposure as well as what trimester you’re in when exposed.

  • Alcohol – crosses placenta and enters baby’s blood in same concentration as in your blood, increasing her risk of serious birth defects and long-term problems with her development. Depends on amount you drink, how often and when in pregnancy. In first trimester, when baby’s organs are forming, excessive alcohol can cause organ defects, facial abnormalities or miscarriage. 2nd trimester can affect nerve formation in brain and 3rd trimester can interfere with development of nervous system. May also cause preterm labor. Of babies whose mothers drank heavily while pregnant, 4% develop FAS, a cluster of physical, mental and behavioral disabilities that include growth problems, heart defects, mental retardation, facial abnormalities, and problems with muscle and nerve development.
    • Heavy drinking – some say 4+ a day; other say 2+ a day or binge drinking more than 3 drinks on one occasion. Standard drink is ½ oz of distilled alcohol, one can of beer or 4 oz glass of wine. Avoiding before pregnancy may help you conceive.
  • Smoking – pregnant smokers have a greater risk of miscarriage, placental abruption, stillbirth or infant death. If she has family history of clubfoot, cleft lip or cleft palate, she increase risk. The more she smokes, the greater risk of placenta previa or ectopic pregnancy. Often give birth to babies with low birth weight (with health problems) because of intrauterine growth restriction and a higher risk of preterm birth. Increased risk of SIDS. If live with smokers, risk of SIDS increases even more depending on number of smokers and amount of time exposed to secondhand smoke. Respiratory problems later in life. http://smokefree.gov http://www.cancer.org don’t use smoking substitutes (nicotine patch, gum or nasal spray) during 1st trimester; can increase risk of malformations in baby if used when organs and structures are forming.
  • Illegal Drugs and Prescription Drug Abuse – in 1st trimester baby may develop defect or deformity or may have miscarriage. In 3rd trimester, baby may have intrauterine growth restriction of IUGR (grow slowly) or suffer effects of prematurity because of a preterm birth. Each drug has its own effect and a combination may compound damage to baby. prescription drugs can be just as dangerous to babies as illegal drugs. PCNguide http://www.pcnguide.com/wp-content/uploads/2016/03/4-Hazards-of-Drug-Abuse-in-Pregnancy.pdf

Potentially Harmful Substances and Herbs in Food

  • Caffeine – can raise heart rate and blood pressure, constrict blood vessels, affect ability to sleep, and make you jittery. Also a diuretic (urinate more fluid, more often) and increases amount of calcium you expel in urine. Of coffee, tea, energy drinks, colas and other soft drinks, coffee has most caffeine but amount differs depending on how its made and serving. An 8 oz may have 65-120; decaf has 2-4 mg. 12 oz soda has 54 mg. Several OTC medications have it and chocolate contains a small amount of a caffeine-like chemical. Read labels. Researchers haven’t found any connections between caffeine and birth defects or delayed childhood development, babies in womb probably experience stimulating and diuretic effects. Caffeine can elevate baby’s heart rate and reduce amount of fluid and calcium available for optimal growth. Evidence on connection to miscarriage, intrauterine growth restriction and stillbirth is conflicting and controversial. Various factors influence including woman’s unique susceptibility – when in pregnancy, how much etc. Large amounts at any time may harm baby; more than 200 mg in 1st trimester may increase risk of intrauterine growth restriction or miscarriage.
  • Herbal Tinctures, Teas and Capsules – FDA hasn’t tested or approved and safety uncertain. Some caregivers recommend red raspberry leaf to tone uterine muscles. Some recommend herbs that can start labor – blue cohosh, evening primrose and black cohosh; however, women should avoid these uterine stimulants in early pregnancy because they may cause miscarriage. Can also have dangerous side effects; blue cohosh may cause elevated blood pressure, irritated mucous membranes and multi-organ injury from lack of oxygen. Some Chinese herbal medicines, specifically An-Tai-Yin and Huanglian, may cause congenital malformations. If allergic to ragweed and related plants, may develop allergic symptoms after drinking chamomile tea. Licorice root tea can increase water retention and decrease potassium. Ginseng can cause swollen and painful breast. Be aware of ingredients of herbal tea before drinking.

Mercury; Other substances that cause harmful illnesses such as listeriosis and toxoplasmosis – pg 121

 

Environmental Hazards and Harmful Situations – abusive relationships, workplace stress

  • Abuse/Domestic Violence – (any combination of verbal, psychological, emotional, sexual, economic or physical) can happen regardless of socioeconomic, educations etc. when pregnant, abuse increases risk of serious pregnancy problems such as high blood pressure, vaginal bleeding, severe nausea or vomiting, UTIs, preterm birth, a baby with low birth weight, or a baby who needs intensive care. Risk of being killed by an abusive partner increases during pregnancy. You are not at fault; goal of abuse is to leave you feeling confused, ashamed, powerless, hopeless and out of control. Suggestions for coping with stress pg 72-73. 800-799-SAFE. Make an escape plan.
  • Insecticides, Herbicides and Pesticides – avoid frequent, sustained exposure to chemicals that kill insects (insecticides), weeds (herbicides), or unwanted insects, bugs or animals (pesticides). Presence of these in the air and on food may cause miscarriage, poor growth in baby, birth defects, and childhood neurobehavioral problems. To avoid exposure, wash fruits and vegetables well.
  • Occupational Hazards – potential harm of some workplace chemicals such as anesthetic agents, benzene, cancer treatment (cytotoxic) drugs, carbon monoxide, ethylene oxide, ethylene glycol ethers, formaldehyde, ionizing radiation (x-ray), lead, methyl mercury, organic solvents, polybrominated biphenyls (PBRs), and polychlorinated biphenyls (PCBs). Can cause miscarriage, birth defects, low birth weight, preterm birth, developmental delays and childhood cancers. People who encounter include health care workers (dental/veterinary), pharmacists, batter makers, solderers, welders, radiator repairers, industrial painters, home remodelers, and atomic and electronic workers. Farm workers exposed to pesticides.
  • Chemicals Used for Hobbies – see Material Safety Data Sheet (MSDS) from store that sells it
  • House Paint – discourage women from using spray paint (because inhale paint particles), but rolling/brushing probably safe. Use low VOC or no VOC paints, which contain fewer (or no) harmful volatile organic compounds. Wear gloves. If hom contains lead-based paint (older homes), don’t remove or paint over yourself. Professional can come and handle toxic paint and dust without harm to you.
  • Hair treatments – some studies show link between it an increased risk of childhood brain tumors, but results aren’t statistically significant. Other studies find no evidence that dyes cause birth defects. No direct evidence that wave solutions or hair relaxers are harmful.
  • Saunas, Hot Tubs and Heat Wraps – may raise baby’s temperature along with yours. Once overheated, baby takes much longer than you to cool down. In early pregnancy, high temps can cause birth defects or even miscarriage. Later in pregnancy, can raise your body temp and produce fever in baby and may cause baby to develop neurological disorders such as seizures. Keep temp below 102.2 and keep should and arms out of water. Consider warm bath instead where less of body is submerged in water.
  • Electric Blankets – emit low-frequency electromagnetic energy, may harm pregnancy if exposure is prolonged and close to body. Consider using down comforter or wool blankets instead.
  • Ionizing Radiation – X rays for medical and dental diagnoses use much less radiation than does radiotherapy for cancer treatment. Because risk of defects from one diagnostic x ray (about 1 radiation absorbed dose, or rad) during first 4 months is tiny, many don’t consider it dangerous. Try to avoid x-rays in first trimester, when radiation may interfere with baby’s organ development.
  • Infectious disease – toxoplasmosis, Lyme disease, rubella (German measles), chicken pox, fifth disease (parovirus B19), listeriosis, hepatitis, and STIs (pg 132-133)
  • Father’s Exposure to Hazards and Drugs – mans exposure months before conception may increase miscarriage risk, childhood brain tumors, and other problems. Research differs about effect of smoking on male fertility
  • Internet Resources fda.gov, www.marchofdimes.com , www.epa.gov , www.ewg.org , www.cdc.gov , www.cdc.gov/niosh , www.osha.gov

 

Holding back during descent phase – may tense pelvic floor in response to stretching sensations you feel when baby’s head is in birth canal. This is normal and usually passes quickly once you feel baby descending. To stop self from holding back, try telling yourself to let go. If successful, pain decreases and you wont have a desire to hold back again. However, you may have trouble letting go for 1 or more of the following reasons

  • Pressure of baby’s head within vagina alarms you and you find it difficult to give in to that pressure – remind self that holding back tends to increase pain and slow progress. You’ll feel much better after letting go. Listen to partner, doula and caregiver when they encourage you to let go. Try sitting on toilet for a few contraction. May help perineal muscles release naturally because its associated with letting go. Warm compresses on perineum can help because moist heat promotes relaxation and relieves stretching sensation. Can also alleviate perineal pain and reduces risks of tearing and urinary incontinence. Also helps reassure you that they will help guide baby out. Discuss with caregiver before due date and include in birth plan. Some caregivers use fingers to stretch woman’s perineum; research finds that this is very painful and no more effective for enlarging vaginal outlet and preventing a tear than use of warm compresses or no treatment.
  • You’re uncomfortable with having people stare at your perineum – they are watching progress of baby, but ask to be covered as much as possible. Warm compresses can conceal perineum
  • You fear you’ll have a bowel movement while pushing – because baby presses on rectum while descending. Caregiver interprets this as progress. May not even be aware of it because caregiver wipes away and removes stool discreetly (perhaps with a warm compress). Sitting on toilet for a few contractions may help you dispel this fear and relax.
  • If you’ve been sexually abused, you fear that the sensation of your baby in your vagina will remind you of your abuse – tell yourself that you’re pushing your pain out of your body as you push out your baby. its important to separate your abuse from the birth of your child. Pg 59

 

Abuse and Domestic Violence – any combination of verbal, psychological, emotional, sexual, economic or physical affects rural and urban women of all ages, physical abilities and lifestyles and of all religious, ethnic, socioeconomic and educational backgrounds. Only risk factor is being a woman and risk increases during pregnancy and especially after birth

If in an abusive relationship, you are not at fault. Goal of abuse is to leave you feeling confused, ashamed, powerless, hopeless and out of control. National Domestic Violence Hotline 800-799-SAFE. Call if you need to talk to someone or need resources or need help making an escape plan for you and your children.

Single Parenthood – 30% of new mothers are single parents, some by choice and others by circumstance. For some, money is tight and they need to find affordable childcare and return to work soon after birth. Others have jobs that pay well and provide excellent maternity leave benefits. For others, father may provide financial support or family members may provide a home and help with childcare.

If you’re a single mother, you’ll need support as you recover from birth and gain confidence as a new parent. New parenthood can be socially isolating, especially if there aren’t’ adults to talk to in the days following the birth. Organizations and networks provide single mothers with opportunities to talk with one another. See singlemothers.org or singlemothersbychoice.com to learn more.

Returning to work – by 3 months after giving birth, 60% of employed, first time mothers in U.S. return to work. During pregnancy, 3 month leave may seem reasonable; however by 3rd postpartum month, new mothers are just getting to know their babies and establishing a relationship with them. Many women dread having to leave babies in someone else’s care, especially when no other options area available.

In addition to finding suitable and affordable child care, mothers need to figure out how to get babies to and from care location. Breastfeeding moms must determine how much to pump and store. If either mom or baby has health complications or feeding difficulties or if mom has PPMD or stressful/unsupportive job, returning to work can be more challenging. Once back at work, many moms worry how sleep deprivation will affect ability to function.

If child care options are unacceptable or work situation is unbearable, try to negotiate with employer for delayed return to work, work shorter or flexible hours or work part time or from home. If these aren’t possible, you and family will need to ask yourself some tough questions – should you quit, try to find another job, can family budget work without your income, how much energy do you want to devote to improving workplace attitude toward new parents and families.

If you want to improve maternity and family benefits in U.S, support political groups such as MomRising.

 

Involving Consumers and Promoting Self-Management – appealing because of potential to reduce health care costs. Maternity care well suited since childbearing is primarily healthy focuses, women usually well when enter system, and visits can prevent opportunity for interventions.

International Concerns – access to prenatal care and family planning education, care for women experiencing postpartum hemorrhage, obstructed labors w no access to hospital care or operative birth, fistulas due to obstructed labors, and HIV positive parents are major international concerns. High maternal/infant mortality in developing countries is serious problems w limited resources to address. Other concerns are genital mutilation and human trafficking.

Female genital mutilation, infibulation (surgical closure of labia majora), and circumcision terms used to describe procedures in which part of all of female external genitalia is removed for cultural on nontherapeutic reasons. In, U.S, performing on women <18 is a crime.

Human trafficking is a $32 billion business that exists in U.S. and internationally. Trafficked individuals, mostly women and children, are forced into hard labor, sex work and even organ donation. Health care workers may interact w those in captivity, which provides and opportunity to intervene. National Human Trafficking Resource Center can help.

Women’s Health – heart disease is leading cause of death of women followed closely by malignant neoplasms including breast cancer. Symptoms different for women and men. Early detection through mammography can reduce mortality rate. Because of lack of info or lack of insurance and access, many women never have mammograms. Wide disparity between Caucasian women and those of other races and between older and younger women in rates of mammography, detection, treatment and survival rates. Cancer genetic predisposition testing increasingly available.

Various factors/conditions affect women’s health. Race a major factor: Caucasian women born in 2015 have a life expectancy of 81.8 yrs, in contrast w 78.2 yrs for African-American women. Population has grown older: approx. 50 m women are 50+; 51 is median age for menopause. Hormone replacement therapy for menopausal women has been used for many years and has both benefits and risks.

Violence is a major factor affecting women; includes battery, rape or other sexual assaults and attacks w various weapons. Rates of reported intimate partner violence have increased, possibly because of better assessment and reporting mechanisms. Approx. 4-8% of pregnant women are battered; incidence increases during pregnancy. Violence is associated with complications of pregnancy such as bleeding. Alcoholism and substance abuse by woman and her abuser are associated w violence and homelessness, which affect a growing # of women and children and place them at risk for a variety of healthy problems.

 

Gynecologic Conditions – women at risk throughout reproductive years for pelvic inflammatory disease, endometriosis, STIs and other vaginal infections, uterine fibroids, uterine deformities such as bicornuate uterus, ovarian cysts, interstitial cystitus and urinary incontinence related to pelvic relaxation. Risk for most cancers is low in pregnancy.

Female Genital Mutilation – practiced in more than 34 countries, the majority of which are in Africa. Partial or total removal of external female genitalia for non-medical reasons. Untoward consequences – severe pain, shock, hemorrhage, tetanus or sepsis, urine retention, open sores and injury to nearby genital tissues. Long term consequences include bladder and UTIs, cysts, infertility and increase risk for complications during childbirth and newborn death. It is an attempt to control women through controlling their sexuality. FGM is supposed to remove sexual desire so that the girl will not become sexually active until marriage.   In U.S., it’s punishable by fines, prison and deportation.   Ob may incise the closed labia to allow for a vaginal birth, or remove cysts but may not sew the labia back to it’s previous state. If performed on a minor, considered child abuse. In growing number of women who have emigrated from Middle East, Asia and Africa. Must be sensitive, esp if women have concerns about maintaining or restoring the intactness of the circumcision after childbirth

Violence Against Women – intimate partner violence (IPV) is the most common form of violence experience by women worldwide, with a reported incidence of 1 of every 6 women having been a victim of domestic violence. 1 in 4 in US has experience severe physical violence by a current of former intimate partner. Pregnancy often a time when violence begins or escalates. Most underreported data as a result of fear, lack of understanding and stigma surrounding violent situations.

 

Fetal factors (excessive pain and duration of prelabor or latent phase): OP position of fetus/brow, face presentation or large unengaged fetal head.

Emotional factors– extreme fear, anxiety, loneliness, stress or anger before or during labor may lead to a buildup of catecholamines and a resulting slowdown in progress.

Women who are not supported emotionally or who have experienced previous difficult childbirths; traumatic experiences such as emotional, physical or sexual abuse; substance abuse; multiple hospitalizations or their experiences may find early labor unexpectedly painful or traumatic.

Exhaustion, discouragement and feelings of hopelessness may result from a long prelabor or latent phase. Woman’s optimism and coping ability diminish and her pain worsens as time goes on without apparent progress.

Sometimes helpful to ask woman about her emotional state during latent labor. Between contractions, ask “What was going through your mind during that contraction”, “How are you feeling right now?” or “Why do you think this labor is going slowly right now?”

Women having painful nonprogressing prelabor or early labor often appear to be much further along in labor than they truly are. Contractions may be so intense that women must rely on coping strategies that others might not use until late in 1st stage. They may also become discouraged and hopeless. Do not discount/minimize their pain; it does not help them cope and only results in their feeling inadequate or unsupported.

If fetal distress, macrosomia, malpresentation, inadequate contractions or other complications are diagnosed, the supportive measures will have to be tailored to the situation.

Troubleshooting Measures for Painful Prolonged Prelabor or Latent Phase:

  • For pain and discouragement that may accompany some labor inductions or an unripe/scarred cervix, reassure the woman that under these circumstances early labor is more challenging, but it does not necessarily mean that active labor will be abnormal
  • Such women also need validation, intense emotional support and physical comfort. Try not to contribute to her self-doubt or worries by suggesting something is wrong
  • If she is discouraged over slow dilation or nonprogressing contractions, remind the woman that before her cervix can dilate, it must move forward, ripen and efface- each of which is a positive sign of progress. Disclose any progress. See six ways to progress.
  • Avoid term “false labor”. If cervix is changing at all, prelabor contractions are preparing cervix for dilation
  • Encourage her to seek and use positions/movements she finds more comfortable
  • Offer bath, shower or massage as temporary relaxer and pain reliever
  • TENS may be especially useful to relieve back pain during early labor. More useful for back pain than for other labor pain and more beneficial when introduced early in labor. Do not restrict woman to bed. Before restricting woman with ruptured membranes to bed (Requirement in many hospitals even if fetal head is engaged), caregiver might auscultate fetal heart and assess fetal movement with woman in upright position. Sometimes upright position actually protects against a prolapsed cord, as gravity may keep head applied to cervix, thus preventing cord from slipping through.
  • Many caregivers, esp in N America, restrict woman with pregnancy-induced hypertension to bed in late pregnancy and in labor, because bp is usually lowered while a woman lies on her left side. Whether treatment has resulted in improved outcomes or less progression of preeclampsia is not known. If caring for a woman in bed with pregnancy-induced hypertension, explain why left-sided bedrest is being asked of her. Help her focus on comfort measures she can use while in bed. Relaxation, rhythmic breathing, vocalization, guided imagery, visualizations, other attention-focusing measures, and massage of her back/feet may help. If limited walking acceptable, she may walk to and form bathroom to use shower or bath (Both which lower high bp). Having choices boosts morale
  • Assess woman’s emotional state during early labor.
  • For exhaustion, discouragement and hopelessness, can raise her spirits by suggesting a change: wash face, comb hair, brush teeth, take walk, play upbeat music. Esp effective if sun comes up after long night with little progress. New day can renew sprits
  • Have good talk with her and partner, encouraging them to express feelings. Acknowledge and validate their feelings of frustration encouragement, fatigue or even anger at staff for not doing something to correct problem. She may benefit from good cry, followed by pep talk and visit from friend or family member who is well rested
  • If above unsuccessful, drug induced rest with alcohol, sleep medication or pain reliever may be appropriate choice

 

Predisposing factors for emotional dystocia – she probably can’t simply “step out of it”; may result form preexisting factors:

  • Previous difficult births
  • Previous traumatic hospitalizations
  • Childhood abuse or neglect: physical, sexual or emotional
  • Dysfunctional family of origin (mental illness, substance abuse, fighting parents etc)
  • Fears about current serious health problems for herself or baby
  • Domestic violence (previous or present)
  • Cultural factors, including beliefs leading to extreme shame when viewed nude or when viewed in labor by men or when behaving in a way that is contrary to cultural expectations
  • Language barriers, or inability ot hear or understand what is happening or being done
  • Death of her own mother (esp in childbirth or at a young age)
  • Beliefs resulting from what she has been told about labor ( ex. Sibling handicapped by birth injury or whose mom had a terrible time giving birth to her)
  • Helping woman state her fears: ask what was going through head during contraction, how woman is feeling right now or if she has any idea what may be slowing labor

 

Special needs of childhood abuse survivors:

A woman who was sexually or physically abused as a child may have great anxieties in labor, esp related to:

  • Invasive procedures that remind her of abuse, such as: vaginal exams, instruments and fingers placed in the vagina, blood draws or IV lines
  • Lack of control: as a child she was hurt when she was out of control and vulnerable. She may have learned never to lose control
  • Modesty, nakedness, exposure issues
  • Powerful authority figures (midwives, nurses, doctors) who know more than she and who do painful things to her: as a child she was a victim of those with authority over her
  • Being asked to “relax, surrender, or yield to the contractions” with the promise that it will not hurt so much: she may have been told similar things during the abuse
  • Pushing her baby out of her vagina: the pain and prospect of damage may remind her of sexual abuse.

Sometimes an abuse survivor seems difficult or demanding when she responds very emotionally or angrily in above situations. Important to not take it personally and keep in mind woman has very good reason to react the way she does and caregiver is not the reason. Try to be patient, kind and listen to her and to meet her special needs to extent possible, even if they seem unusual or unreasonable. If she feels emotionally safe, her labor may progress more normally and may reap other psychological benefits as well.

 

Anxiety or distress in labor

Anxiety or distress in labor: “emotional dystocia” -à check psychosocial history; comfort measures (bath/shower, massage/soothing touch, breathing/relaxing), psychological interventions (what’s going through mind, reassurance/education, visualizations), kindness/respect, accommodate women’s special needs as possible, patience, doula -à improved labor progress OR rest with narcotics and/or epidural (depending on phase) à oxytocin, AROM à cesarean section

 

Signs of emotional distress in 2nd stage

  • Verbal or facial expressions of fear
  • Crying or panic
  • Inability to get beyond holding back to releasing the pelvic floor
  • Holding legs together
  • Diffuse bearing down
  • Begging caregiver to take baby out or to knock her out with drugs
  • Desperation, inability to follow caregiver’s suggestions

 

  1. Early vaginal bleeding

Chronic Conditions That May Affect Your Pregnancy – chances of having healthy baby by controlling symptoms before becoming pregnant; create plan with caregiver

  • Cardiovascular disease (high blood pressure, heart disease or sickle cell anemia)
  • Gastrointestinal illness or nutrition problems (inflammatory bowel disease, phenylketonuria or PKU, Crohn’s disease, eating disorders or gastric bypass surgery)
  • Respiratory or lung disease (asthma)
  • Hormonal imbalance or disease (diabetes, thyroid disease, polycystic ovarian syndrome or PCOS or pituitary disorders)
  • Autoimmune disorder, in which the immune system harms instead of protects body (rheumatoid arthritis, lupus erythematous, and antiphospholipid antibody syndrome or APS)
  • Other conditions of illness (kidney disease, epilepsy, or physical disability)

Complications that arise in pregnancy

  • Vaginal bleeding in early pregnancy – spotting/light vaginal bleeding in first trimester occurs in 20% of all pregnancies. In many cases, bleeding doesn’t harm mom or baby. sometimes, implantation of fertilized egg into uterine wall causes slight vaginal bleeding, usually shortly before the time a woman expects a menstrual period. Other times, cervical tenderness and an increased blood supply to pelvis can cause spotting after a woman has intercourse. Frequent strenuous exercise or a cervical infection causes vaginal bleeding. In rare cases, a condition called molar pregnancy causes brownish vaginal discharge in early pregnancy. In a molar pregnancy, abnormal placental tissue grows into a grape-like cluster; there isn’t a baby, even though a pregnancy test is positive.
    • For about half of women who experience bleeding in early pregnancy, bleeding stops on its own and many women have no further complications. In other cases, it’s serious and sometimes indicates an ectopic pregnancy or possible miscarriage. Women who have continuous moderate or heavy bleeding are more likely to miscarry than those who experience light bleeding only once. Call caregiver. Rest and avoid strenuous exercise and sex. Caregiver may order ultrasound or blood tests.

 

  1. Ectopic pregnancy

Ectopic pregnancy – 1-2% of pregnancies; occurs when fertilized egg implants itself someplace outside uterus, usually in wall of a fallopian tube (tubal pregnancy), but sometimes in cervix, ovary or abdomen. Wont results in a live birth. Symptoms appear in first 6-8 weeks and may include lower abdominal pain or tenderness (or one-sided pelvic pain) and vaginal bleeding. Additional symptoms include nausea, vomiting, dizziness or sharp shoulder pain. Untreated causes severe abdominal pain and vaginal bleeding that indicates internal bleeding.

Early diagnosis and rapid treatment help preserve a woman’s future fertility and greatly reduce risk of death from severe blood loss after a tube ruptures. Caregiver assesses woman’s hormone levels to evaluate viability of pregnancy and examines a high-resolution ultrasound scan to discover the implantation site. Surgery may be needed to confirm diagnosis or to remove embryo. IV infusion called methotrexate maybe be used to abort pregnancy or may be combined with surgery to ensure the full removal of pregnancy tissues.

Likelihood of ectopic pregnancy rises for women whose fallopian tubes are damaged by pelvic infections, disease or surgery. Majority of woman can expect to get pregnant again and carry a healthy baby to term.

 

  1. Miscarriage

Miscarriage– aka spontaneous abortion is unexpected death and delivery of baby before 20th week of pregnancy. 10-15% of known pregnancies end in miscarriage; % of early miscarriage (1-13 weeks) higher because many women might not realize they’re pregnant. No one knows specific cause of most miscarriages; most commonly suspected reason is random chromosomal abnormalities. Other reasons that increase risk include history of infertility, assisted conception, advanced age of woman or man, high body temp, infection, hormonal imbalance, high intake of alcohol or caffeine, smoking, low body weight along with poor diet, frequent high-impact or strenuous exercises and extreme emotional stress or physical injury.

Factors that increase risk of late miscarriages (14-20 weeks) include uterine abnormalities such as incompetent cervix, acute infection, placental circulation problems, uterine fibroids, certain chronic illnesses (such as autoimmune disorders; uncontrolled diabetes; thyroid conditions and hear, liver or kidney disease). Treatment of these possible causes can help prevent miscarriage.

Once a miscarriage starts, it can’t be stopped. Signs include vaginal bleeding and intermittent abdominal pain that often begins in lower back and develops into abdominal cramping. Call caregiver; they might advise you to rest and see if bleeding stops or may order ultrasound and blood test to confirm if still pregnant. If had miscarriage and Rh negative, may receive shot of Rhogam.

Sometimes a caregiver discovers baby has died before miscarriage begins. Some women want immediate end to pregnancy by receiving medications to expel baby or by having surgery to clean out uterus (dilation and curettage or D&C). if you decide against them, stay within a 30 min drive to hospital in case you experience heavy bleeding, fever or strong abdominal pains while awaiting the miscarriage. Surround yourself with people who can support and nurture you during this difficult time. Books and support groups. Most women who have 2 or more miscarriages eventually give birth to healthy babies. Consider asking caregiver about medical tests or genetic counseling to determine possible cause, to screen for genetic disorders and to treat harmful infection or chronic condition.

To improve chances of a healthy pregnancy after previous miscarriage: have well-balanced diet, take prenatal vitamins, avoid environmental toxins and infections, don’t smoke or use recreational drugs, avoid extremely stressful relationships as much as possible before and during pregnancy and make arrangements for emotional support and medical monitoring, starting in early pregnancy.

 

Clinical Manifestations – signs and symptoms of miscarriage depend on duration of pregnancy. The presence of uterine bleeding, uterine contractions, or abdominal pain is an ominous sign during early pregnancy and must be considered a threatened miscarriage until proven otherwise.

If it occurs before 6th weeks of pregnancy, woman may report what she believes is a heavy menstrual flow. Bw 6-12 weeks, it causes moderate discomfort and blood loss. After week 12, typified by severe pain, similar to that of labor, because fetus must be expelled. Diagnosis of the type if based on signs and symptoms.

Symptoms of threatened miscarriage include spotting of blood but w cervical os closed. Mild uterine cramping may be present.

Inevitable and incomplete miscarriages involve a moderate to heavy amount of bleeding with an open cervical os. Tissue may be present w bleeding. Mil to severe uterine cramping may be present. Inevitable miscarriage often accompanied by rupture of membranes (ROM) and cervical dilation. Passage of products of conception occurs. Incomplete involves expulsion of fetus w retention of placenta.

In complete miscarriage, cervix has already closed after all fetal tissue expelled. Slight bleeding may occur and mild uterine cramping may be present.

Missed miscarriage refers to pregnancy in which fetus has diet but products of conception are retained in utero for up to several weeks. May be diagnosed by ultrasonic examination after uterus stops increasing in size or even decreases in size. May be no bleeding or cramping, and cervical os remains closed.

Recurrent (habitual) early miscarriage is 3+ spontaneous pregnancy losses before 20 weeks gestation. Most widely accepted causes are parental chromosomal abnormalities, antiphospholipid antibody syndrome, and certain uterine abnormalities.

Evaluation of couples experiencing recurrent pregnancy loss usually includes karyotyping of both partners and miscarriage specimens and assessment of placenta; evaluation the pholipid antibody syndrome and thyroid disease. Evaluation should also address the psychological response to this diagnosis because women and their partners often report feelings of guilt, anxiety and depression. Couples experiencing recurrent pregnancy loss should be screened for depression and PTSD.

Miscarriages can become septic, although this is uncommon. Symptoms include fever and abdominal tenderness. Vaginal bleeding, which may be slight to heavy, is usually malodorous.

Assessment and Nursing Diagnoses – whenever a woman has vaginal bleeding early in pregnancy, a thorough assessment should be performed. Data to be collected includes pregnancy history, vital signs, type and location of pain, quantity and nature of bleeding and emotional status. Lab tests may include evaluation of hCG (pregnancy), hemoglobin level (anemia) and white blood cell count (infection).

Following nursing diagnoses appropriate for woman experiencing miscarriage:

  • Anxiety related to unknown outcome and unfamiliarity w medical procedures
  • Deficient fluid volume related to excessive bleeding secondary to miscarriage
  • Acute pain related to uterine contractions
  • Situational low self-esteem related to inability to carry a pregnancy successfully to term gestation
  • Risk for infection related to surgical treatment and dilated cervix.

 

 Assessing Miscarriage and Usual Management

Type: Amount of Bleeding/Uterine Cramping/Passage of Tissue/Cervical Dilation/Management

  • Threatened: slight, spotting/mild/no/no/bed rest often ordered but has not proven to be effective in preventing progression to actual miscarriage. Repetitive transvaginal ultrasounds and assessment of hCG and progesterone levels may be done to determine if fetus is still alive and in uterus; further treatment depends on whether progression to actual miscarriage occurs
  • Inevitable: moderate/mild to severe/no/yes/bed rest if no pain, bleeding or infection. Ir rupture of membranes (ROM), pain, bleeding or infection is present, then prompt termination of pregnancy is accomplished usually by dilation and curettage
  • Incomplete: heavy, profuse/severe/yes/yes, w tissue in cervix/may or may not require additional cervical dilation before curettage
  • Complete: slight/mild/yes/no(cervix has already closed after tissue passed)/no further intervention may be needed if uterine contractions are adequate to prevent hemorrhage and no infection is present
  • Missed: none, spotting/none/non/no/if spontaneous evacuation of uterus does not occur within 1 month, pregnancy is terminated by method appropriate to duration of pregnancy; blood clotting factors are monitored until uterus is empty; disseminated intravascular coagulation (DIB) and incoagulability of blood w uncontrolled hemorrhage may develop in cases of fetal death after 12th week, if products of conception are retained for longer than 5 weeks; may be treated with dilation and curettage or misoprostol (Cytotec) given orally or vaginally
  • Septic: varies, usually malodorus/varies/varies/yes, usually/immediate termination fo pregnancy by method appropriate to duration of pregnancy; cervical culture and sensitivity studies are performed, and broad-spectrum antibiotic therapy (ampicillin) is started; treatment for septic shock is initiated if necessary
  • Recurrent: varies/varies/yes/yes, usually/varies; depends on type; prophylactic cerclage may be performed if cervical insufficiency is cause. Tests of value include karyotyping of both partners and miscarriage specimens and assessment of placenta; evaluating woman’s uterine cavity; and testing woman for antiphospholipid antibody syndrome and thyroid disease.

 

  1. Fever

High Body Temp (Fever) – (>100.4F or 38C) for 3-4 days may harm baby, especially in early pregnancy. Don’t take any fever reducing medication. To lower temp, drink plenty of liquids and take lukewarm bath/shower. If temp is higher than 102F (38.9C), call caregiver immediately. Hot tubs/saunas may raise body temp to level that can be dangerous to baby.

 

  1. Hyperemesis gravidarum

Severe Nausea and Vomiting (Hyperemesis Gravidarum)

Persistent, severe nausea and vomiting. Affects less than 1% of pregnancies, can result in weight loss, dehydration, and changes in blood chemistry. If you continue to vomit food and fluids for a day or longer, call caregiver to determine whether cause is illness or food poisoning. Early management may help prevent its progression. Treatment begins with same dietary/lifestyle changes recommended for managing morning sickness, along with suggestions for helping you keep down foods and fluids. If this isn’t effective, caregiver may prescribe medications to relieve vomiting (antiemetics) and if necessary, to treat infection. If vomiting can’t be controlled, may need hospitalization to receive IV fluids. Sometimes, psychological problems can worsen so talking with a trained counselor may help.

  1. Uterine fibroids

Up to 75% of women develop fibroids (aka leiomyomas or myomas) at some time during their lives, but they usually don’t cause problems. During childbearing years, less than 25% of women with fibroids experience symptoms such as excessive menstrual bleeding, pelvic pain or infertility; only some have surgery to shrink or remove them.

 

Procedure: Leopold Maneuvers

  • Wash hands
  • Ask woman to empty bladder
  • Position woman supine w 1 pillow under her head and w knees slightly flexed
  • Place small rolled towel under woman’s right or left hip to displace uterus off major blood vessels (prevents supine hypotension syndrome)
  • If right handed, stand on woman’s right, facing her (if left, face left)
    • Identify fetal part that occupies fundus. Head feels round, firm, freely movable and palpable by ballottement; breech feels less regular and softer.   This maneuver identifies fetal lie (longitudinal or transverse) and presentation (cephalic or breech)
    • Using palmar surface of 1 hand, locate and palpate the smooth convex contour of the fetal back and irregularities that identify the small parts (Feet, hand, elbows).
    • With right hand, determine which fetal part is presenting over the inlet to the true pelvis. Gently grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly. If head is presenting and not engaged, determine the attitude of the head (Flexed or extended).
    • Turn to face woman’s feet. Using both hands, outline fetal head w palmar surface of the fingertips. When presenting part has descended deeply, only a small portion of it may be outlined. Palpation of the cephalic prominence helps identify the attitude of the head. If the cephalic prominence is found on the same side as the small parts, this means that the head must be flexed and the vertex is presenting. If cephalic prominence is on the same side as the back, this indicated that the presenting head is extended and face is presenting.
  • Document fetal presentation, position and lie and whether presenting part is flexed or extended, engaged or free floating.

Assessment of Fetal Heart Rate and Pattern – point of maximal intensity (PMI) of the FHR is the location on the maternal abdomen at which FHR is heard the loudest. It is usually directly over the fetal back. In a vertex presentation, you can usually hear the FHR below the mother’s umbilicus in either the right or the left lower quadrant of the abdomen. In a breech presentation you usually hear the FHR above the mother’s umbilicus. Must assess FHR after ROM because this is the most common time for the umbilical cord to prolapse, after any change in the contraction pattern or maternal status, and before and after the woman receives medication or a procedure is performed.

Correcting Fetal Malpresentations: Version and Moxibustion: noncephalic presentation (breech or transverse) makes vaginal birth risky or impossible and is a common reason for scheduled cesarean. Malpresentations can sometimes be corrected. Ideally correction occurs before engagement of the presenting part in the pelvis (dropping), yet close enough to term to maintain the position until birth and minimize the risk of preterm birth.

External cephalic version (ECV) is an ultrasound-guided, hands-on procedure to externally manipulate the fetus into a cephalic lie. Its done at 36-37 weeks, in hospital setting.

  • Beta stimulants to relax the uterus, such as terbutaline, have the best evidence for premedication
  • Successful outcome of vaginal birth most likely for multiparous women w adequate amniotic fluid
  • Even w successful ECV, women are still at a greater risk for cesarean birth, esp if nulliparous and labor is induced.

Postural management, the practice of position women w pelvis elevated, does not have sufficient evidence to support it as an effective corrective technique.

Moxibustion, the Chinese practice of burning lungwort close to acupuncture point 67, the tip of the 5th toe, has promising evidence. Meta-analysis of 8 trials found that moxibustion was associated w less need for oxytocin. When combined w acupuncture or postural management, moxibustion may result in fewer cesareans.

Promoting cephalic vaginal birth is protective against the complications of cesarean birth, which includes a high risk for future cesareans

  • Even w uterine relaxers, ECV is very uncomfortable or painful, and carries its own risks for placental abruption, cord accident, and emergent cesarean. Women benefit from having a support person present.
  • Moxibustion is a welcome noninvasive technique that shows promise and does no harm.   Proper training is required to avoid burns and respiratory reaction. Of practical concern to consider is the venting of smoke, to avoid triggering smoke alarms. Lack of familiarity prob impedes its uptake.

Women w malposition need to understand the mechanics of vaginal birth, and the risk factors for all options. Some women may prefer a cesarean, even w its increased risks.

ECV is well accepted, but painful and risky. Postural management has insufficient evidence, but moxibustion may be a noninvasive and safe way to correct malposition.

Assessment of Uterine Contractions – a general characteristic of effective labor is regular uterine activity (contractions becoming more frequent w increased duration), but uterine activity is not directly related to labor progress. Uterine contractions are the primary powers that act involuntarily to expel the fetus and the placenta from the uterus. Several methods are used to evaluate uterine contractions, including the woman’s subjective description, palpation and timing of contractions by a health care provider, and electronic monitoring.

Each contraction exhibits a wavelike pattern. It begins w a slow increment (building up of a contraction from its onset), gradually reaches a peak and then diminishes rapidly (decrement, the letting down of the contraction). An interval of rest ends when the next contraction begins. The outward appearance of the woman’s abdomen during and between contractions and the pattern of a typical uterine contraction are in Fig 19-6.

A uterine contraction is described in terms of the following characteristics:

  • Frequency: how often uterine contractions occur; the time that passes from the beginning of 1 contraction to the beginning of the next
  • Intensity: strength of contraction at its peak
  • Duration: time that passes between onset and end of a contraction
  • Resting tone: tension in the uterine muscles between contractions; relaxation of uterus.

Uterine contractions are assessed by palpation or by using external or internal electronic monitors. Frequency and duration can be measured by all 3 methods of uterine activity monitoring. The accuracy of determining and resting tone varies by the method used. The woman’s description and examiner’s palpation are more subjective and less precise ways of determining the intensity of uterine contractions and resting tone than are the external or internal electronic monitors. The following terms describe what is felt on palpation:

  • Mild: slightly tense fundus that is easy to indent w fingertips (Feels like pressing finger to tip of nose)
  • Moderate: Firm fundus that is difficult to indent w fingertips (feels like pressing finger to chin)
  • Strong: Rigid boardlike fundus that is almost impossible to indent w fingertips (feels like pressing finger to forehead).

Women in labor tend to describe the pain of contractions in terms of the sensations they are experiencing in the lower abdomen or back, which are sometimes unrelated to the firmness of the uterine fundus. Therefore, their assessment of the strength of their contractions can be less accurate that that of health care provider, although amount of discomfort reported is valid.

External electronic monitoring provides some info about strength of uterine contractions when the appearance of contractions on admission is compared with those that occur later in labor. Internal electronic monitoring w an intrauterine pressure catheter, however, is the most accurate way of assessing the intensity of uterine contractions and uterine resting tone.

On admission to a hospital, uterine contractions and FHR and pattern are usually monitored electronically for at least a 20-30 min period as a baseline. The minimal times for assessing uterine activity during the various phases of stage one labor are listed in Table 19-2. Findings expected as 1st stage of labor progresses in Table 19-1.

If you find the characteristics of contractions to be abnormal, either exceeding or falling below what is considered acceptable in terms of the standard characteristics, report this finding to OB.

Must consider uterine activity in the context of its effect on cervical effacement and dilation and on degree of descent of presenting part. Must also consider effect on fetus. Can verify progress of labor effectively through use of graphic charts (partograms) on which you plot cervical dilation and station (descent). This type of graphic charting assists in early ID of deviations from expected labor patterns. Hospitals and birthing centers may develop their own assessment graphs that may include data not only on dilation and descent but also maternal vital signs, FHR and uterine activity.

Nurse should recognize that active labor can actually last longer than expected labor patterns because all women are different. This finding is not a cause for concern unless maternal-fetal unit exhibits signs of stress (abnormal FHR patterns, maternal fever).

 

Vaginal Examination – the vaginal exam reveals whether woman is in true labor and enables examiner to determine whether membranes have ruptured. Because this exam is often stressful and uncomfortable for woman and may introduce microorganisms into the vagina if membranes are ruptured, perform it only when indicated by status of woman and her fetus. Perform on admission, prior to administering medications (analgesics, increasing oxytocin infusion), when significant change has occurred in uterine activity, on maternal request or perception of perineal pressure or urge to bear down, when membranes rupture, or when you note variable decelerations of FHR. A full explanation of exam and support of woman are important in reducing the stress and discomfort associated w the exam.

 

Procedure: Vaginal Exam of Laboring Woman

  • Use sterile glove and antiseptic solution or soluble gel for lubrication
  • Position woman to prevent supine hypotension. Drape to ensure privacy
  • Cleanse perineum and vulva, if needed
  • After obtaining woman’s permission to touch her, gently insert the index and middle fingers into the woman’s vagina
  • Determine
    • Cervical dilation, effacement and position (posterior, mid, anterior)
    • Presenting part, position and station; molding of the head w development of caput succedaneum (may affect accuracy of determination of station)
    • Status of membranes (intact, bulging or ruptured)
    • Characteristics of amniotic fluid (color, clarity and odor), if membranes are ruptured
  • Explain findings of exam to woman
  • Document findings and report them to nurse-midwife or OB

Lab and Diagnostic Tests – Analysis of Urine Specimen – a clean-catch urine specimen may be obtained to gather further data about the pregnant woman’s health. Analysis is a convenient and simple procedure that can provide info about hydration status (specific gravity, color, amount), nutritional status (ketones), infection status (leukocytes) or status of possible complications such as preeclampsia, shown by finding protein in urine. In many hospitals this test must be done in lab rather than at bedside, even if urine dipstick used.

Blood Tests – vary w hospital protocol and woman’s health status. Currently, all blood tests must be performed in lab rather than on perinatal unit. Often samples obtained from hub of catheter when an IV is started or heplock or saline lock is inserted.  A hematocrit will likely be ordered. More comprehensive blood assessments such as white blood cell count, red blood cell count, hemoglobin level, hematocrit, and platelet values are included in a complete blood count (CBC). A CBC may be ordered for women w history of infection, anemia, gestational hypertension, or other disorders. Many hospitals require that a CVC be done before epidural anesthesia is initiated. Any woman whose HIV status is undocumented at time of labor should be screened w rapid HIV test unless she declines testing.

Most hospitals required that a “type and screen” to determine the woman’s blood type and Rh status, be performed on admission. Even if these tests have already been performed during pregnancy, the hospital’s lab or blood bank must verify the results in house. If woman had no prenatal care or if her prenatal records are not available, a prenatal screen will likely be drawn on admission. The prenatal screen includes lab tests that would normally have been drawn at the initial visit.

Other Tests – if woman’s group B strep status isn’t known, a rapid test may be done on admission. The rapid test results are usually available within an hr or so and will determine if woman must be given antibiotics during labor.

Assessment of Amniotic Membranes and Fluid – labor is initiated at term by SROM in ~25% of pregnant women. A lag period, rarely exceeding 24 hrs, may precede the onset of labor. Membranes (the BOW) can also rupture spontaneously any time during labor, but most commonly in the transition phase of the 1st stage of labor. Box 19-1 explains how to determine if membranes are ruptured. If membranes do not rupture spontaneously, the BOW may be ruptured artificially at some time during labor. However, this practice is discouraged if there is no medical reason because it can increase the labor woman’s sensation of pressure and pain and is not necessary for a normal birth to occur.   Artificial rupture of membranes (AROM), called an amniotomy, is performed by the OB using a plastic AmniHook or surgical clamp.

Whether membranes rupture spontaneously or artificially, time should be recorded. Other necessary documentation includes info regarding FHR before and after rupture, the color (clear or meconium stained), estimated amount and odor of fluid.

Umbilical cord may prolapse when membranes rupture. FHR and pattern should be monitored closely for several minutes immediately after ROM to determine fetal well-being, and findings should be documented.

Infection – when membranes rupture, microorganisms from vagina can then ascend into the amniotic sac, causing chorioamnionitis and placentitis to develop. For this reason, limit the # of exams and assess maternal temp and vaginal discharge frequently (at least every 2 hrs) so that you can quickly identify an infection developing after ROM. Even when membranes are intact, however, microorganisms may ascend and cause infection.

Assessment findings serve as a baseline for evaluating the woman’s subsequent progress during labor. Although some problems can be anticipated, others may appear unexpectedly during the clinical course of labor.

Signs of Potential Complications – Labor:

  • Intrauterine pressure >80 mm Hg or resting tone of >20 mm Hg (both determined by internal monitoring w intrauterine pressure catheter (IUPC))
  • Contractions lasting >90 seconds
  • More than 5 contractions in a 10 min period (Contractions occur more frequently than every 2 min)
  • Relaxation between contractions lasting <30 secs
  • Fetal bradycardia or tachycardia; absent or minimal variability not associated w fetal sleep cycle or temporary effects of CNS (central nervous system) depressant drugs given to woman; later, variable or prolonged fetal hear rate (FHR) decelerations
  • Irregular FHR; suspected fetal arrhythmias
  • Appearance of meconium-stained or bloody fluid from the vagina
  • Arrest in progress of cervical dilation or effacement, descent of fetus, or both
  • Maternal temp of >100.4F
  • Foul-smelling vaginal discharge
  • Persistent bright or dark red vaginal bleeding

 

Evidence-Based Care Practices Designed to Promote, Protect, and Support Normal Labor and Birth

  • Allow labor to begin on its own: encourage spontaneous labor rather than fostering elective labor inductions
  • Encourage freedom of movement throughout labor to facilitate progress of labor and enhance maternal comfort and control of the labor process
  • Provide labor support beginning early in labor and continuing throughout the process of childbirth to relieve maternal anxiety and stress and decrease the risk for epidural anesthesia and cesarean birth; support should be provided by someone not employed by hospital
  • Avoid routine implementation of interventions (IV fluids, oral intake restrictions, continuous EFM, labor augmentation measures (amniotomy, oxytocin admin) and epidural
  • Support practice of spontaneous, nondirected pushing in nonsupine positions (lateral, squatting, standing, kneeling and semisitting) to facilitate progress of fetal descent and short 2nd stage of labor
  • Avoid separation of mom from healthy baby after birth by encouraging skin to skin to keep newborn warm, prevent neonatal infection, enhance newborn’s physiologic adjustment to extrauterine life, and foster early breastfeeding.

Nursing Interventions – General Hygiene – often women in labor use showers or warm water baths. Water immersion associated w decrease in use of analgesia and reports of less pain. Encourage women to wash hands or use cleansing foam after voiding and performing self-hygiene measures. Change linen if becomes wet or stained w blood and use linen savers (Chux), changing as needed.

Nutrient and Fluid Intake – Oral Intake – before 1940s, women were allowed to eat and drink during labor to maintain the energy required to sustain labor and stamina required to give birth. This changed, allowing woman only clear liquids or ice chips or nothing by mouth during active phase of labor when concern arose regarding risk of anesthesia complications and secondary effects, if general anesthesia were required in an emergency: aspiration of gastric contents and resultant compromise in oxygen perfusion, which could endanger the lives of mom and fetus. There have been no randomized trials evaluating ingestion of solid foods in labor, so current management based mostly on expert opinion. ACOG recommends avoiding solids during labor. This is being challenged by many providers bc regional anesthesia used more often, even for emergency cesareans. Women are awake and able to participate in own care and protect airway.

Adequate intake of fluids and calories required to meet energy demands and fluid losses associated w childbirth. Progress of labor slows, w a more rapid development of hypoglycemia and ketosis if these demands are not met and fat is metabolized. Reduced energy for bearing-down efforts (pushing) increases risk for forceps or vacuum assisted birth. Most likely to occur in women who begin to labor early in morning after a night w out caloric intake. When women permitted to consume fluid and food freely, they typically regulate their own oral intake, eating light foods (eggs, yogurt, ice cream, dry toast and jelly, fruit) and drinking fluids early labor and tapering off to intake of clear fluids and sips of water or ice chips as labor intensifies and 2nd stage approaches.

Common hospital practice is to allow clear liquids (water, tea, fruit juices w out pulp, clear sodas, coffee, sports drinks, fruit ice, Popsicles, gelatin, broth) during early labor, tapering off to ice chips and sips of water as labor progresses and becomes more active. Herbal teas can provide not only hydration but also other beneficial effects. Chamomile tea ccan enhance relaxation, lemon balm or peppermint tea can reduce nausea and tea of ginger or ginseng root are energizing. A woman’s culture may influence what she will eat and drink during labor. Women who use nonpharmacologic pain relief and labor at home or in birthing centers more likely to eat/drink during labor.   Amount of solid and liquid carbs to offer a woman still unclear. Although its known that energy needs increase as labor becomes prolonged, there is limited evidence regarding effect of oral carb intake in enhancing progress of labor and reducing risk for dystocia.

Cochrane database review concluded there’s no justification for restricting food or fluid intake in women at low risk for complications. Nurses should follow orders but can inform providers of current findings.

Nursing Care Plan – Care of Woman in Labor

  • Anxiety:
    • Explain admission protocol, introduce unit
    • Assess knowledge of labor
    • Discuss expected progression and describe what to expect
    • Identify source of anxiety
    • Actively involve woman in care, interpret sights and sounds of environment and share info on progression (vital signs, FHR, dilation, effacement)
  • Acute pain related to increasing frequency and intensity of contractions
    • Assess level of pain and coping strategies
    • Encourage support person to help
    • Assess in nonpharmacologic pain methods (conscious relaxation, breathing techniques, hypnosis, music, distraction, imagery, massage, touch
    • Comfort measures such as mouth care to prevent dry mouth, application of amp cloth to forehead and changing of damp gown or bed covers
    • Help woman to move around and change positions such as squatting, using birth ball or stool
    • Explain analgesics and anesthesia available
    • Administer analgesics or assist w epidural
  • Impaired urinary elimination related to sensory impairment secondary to labor
    • Palpate bladder superior to symphysis at least every 2 hrs
    • Encourage frequent voiding (at least every 2 hrs) and catheterize if necessary
  • Ineffective coping relating to birthing process
    • Monitor events, including emotional responses of woman and partner
    • Provide ongoing feedback
    • Comfort measures and minimize distractions (dim lights, soft voices)
    • Experiment w different positions
    • Deep cleansing breaths before and after each contraction
    • Push spontaneously when urge to bear down perceived during contraction
    • Exhale, while holding breath for short periods while bearing down
    • Take deep breaths and relax between contractions
    • Pant as fetal head crowns
    • Explain 3rd stage
  • Fatigue related to energy expenditure required during labor and birth
    • Educator about need for rest (restricting visitors, increasing role of support system in daily routines) that allow time for rest and sleep
    • Monitor fatigue level and amount of rest received
    • Group care activities

IV Intake – fluids commonly administered by IV to maintain hydration, esp if labor is long and woman unable to ingest sufficient amount of fluid orally or if received epidural or intrathecal anesthesia. Electrolyte solution w out glucose (Ringer’s lactate or normal saline) does not introduce extra glucose into bloodstream. Important because excessive glucose level results in fetal hyperglycemia and fetal hyperinsulinism. After birth neonates high level of insulin reduces his/her glucose stores and hypoglycemia results. Infusions containing glucose can also reduce sodium levels in woman and fetus, leading to transient neonatal tachypnea. If maternal ketosis occurs, OB can order IV solution containing small amount of dextrose to provide glucose needed to assist in fatty acid metabolism.

Nurses should carefully monitor intake and output of laboring women receiving IV fluids because they face an increased danger of hypovolemia s a result of fluid retention that occurs during pregnancy.

Elimination – Voiding – encourage every 2 hrs. distended bladder may impede descent of presenting part, slow or stop uterine contractions and lead to decreased bladder tone or uterine atony after birth. Women w epidural esp at risk for retention or urine. Need to void should be assessed more frequently w them.

Assist woman to bathroom to void or use bedside commode unless: OB ordered bed rest, woman receiving anesthesia, internal monitoring, ambulation will compromise status of laboring woman. External monitoring can be interrupted long enough for woman to go to bathroom.

If using bedpan necessary, encourage spontaneous voiding by providing privacy and having woman sit upright. Have her listen to sound of water running from faucet, place hands in warm water, have her blow bubbles into glass of water using a straw, pour warm water over vulva and perineum using peri bottle.

Catheterization – if woman unable to void and bladder distended, may need catheter. Before, clean vulva and perineum bc vaginal show and amniotic fluid may be present. If obstacle that prevents advancement of catheter is present, obstacle most likely presenting part. If cannot advance catheter, stop and notify OB.

 

Physical Nursing Care During Labor:

General Hygiene

  • Showers or bed baths, Jacuzzi – supervise if woman in true labor, suggest warm water to flow over back
  • Perineum – cleanse frequently, esp after rupture of membranes and when show increases
  • Oral hygiene – offer toothbrush or mouthwash, or wash teeth w ice-cold wet washcloth
  • Hair- brush, braid per woman’s wishes
  • Handwashing – offer washcloths or cleansing foam before and after voiding
  • Face – offer cool washcloth
  • Gowns and linens – change as needed

Nutrient and fluid Intake

  • Oral – offer fluids and solids as ordered
  • IV – establish/maintain line

Elimination

  • Voiding – encourage every 2 hrs
  • Ambulatory women – allow to bathroom if presenting part engaged, membranes not rupture, woman isn’t medicated
  • Woman on bed rest – offer bed pan, encourage upright position, allow tap water to run, place woman’s hands in warm water, pour warm water over vulva, provide privacy, put up side rails on bed, place call bell and phone w in reach, offer washcloth or foam for hands, wash vulvar area
  • Catheterization – according to OB if voiding ineffective; insert between contractions; avoid force if obstacle noted
  • Bowel elimination – sensation of rectal pressure – perform vaginal exam, help woman ambulate to bathroom or offer bedpan if rectal pressure not from presenting part, cleanse perineum after passage of stool

 

  1. Amnioinfusion

Amnioinfusion – infusion of room temp isotonic fluid (usually normal saline or lactated Ringer’s solution) into uterine cavity if volume of amniotic fluid is low. Without the buffer of amniotic fluid the umbilical cord can easily become compressed during contractions or fetal movement, diminishing the flow of blood between fetus and placenta. Purpose is to relieve intermittent umbilical cord compressing that results in variable decelerations and transient fetal hypoxemia by restoring the amniotic fluid volume to a normal or near-normal level. Women w an abnormally small amt of fluid (oligohydramnios) or no fluid (anhydramnios) are candidates. Conditions that can result in oligohydramnios or anhydramnios include uteroplacental insufficiency, PROM, and anomalies that prevent or reduce fetal urine production.

Risks are overdistention of uterine cavity and increased tone. Fluid administered by IUPC either by gravity flow or by an infusion pump.   Usually a bolus of fluid is administered over 20-30 min and then infusion is slowed to a maintenance rate. Likely no more than 1000 ml of fluid will need to be administered. Fluid can be warmed for preterm fetus by infusion it through a blood warmer.

Intensity and frequency of UCs should be continually assessed during procedure. Recorded uterine resting tone during amnioinfusion appears higher than normal because of resistance to outflow and turbulence at end of catheter. Uterine resting tone should not exceed 40 mm Hg during procedure. The amount of fluid return must be estimated and documented during amnioinfusion to prevent overdistention of uterus. Volume of fluid returned should be approx. same as amount infused.

 

Uterine Fibroids – up to 75% of women develop fibroids (aka leiomyomas or myomas) at some time during their lives, but they usually don’t cause problems. During childbearing years, less than 25% of women with fibroids experience symptoms such as excessive menstrual bleeding, pelvic pain or infertility; only some have surgery to shrink or remove them.

Venous thrombosis – blood clot that typically occurs in a vein in leg or pelvis. Pressure from enlarged uterus slows flow of blood returning from legs and blood changes how it clots to help reduce postpartum bleeding so have slightly increased risk of developing blood clots in legs during pregnancy or soon after birth.

Clot that develops in a vein close to skin is called thrombophlebitis and it causes swelling, tenderness and redness. Treatment includes bed rest with leg elevated, hot packs to affected area, special support stockings and a mild pain reliever if needed.

Deep vein thrombosis (DVT) develops in a big vein that’s deeper in your body and is much more serious than thrombophlebitis. DVT causes leg or pelvic pain and redness, warmth or swelling near the affected area. If you have DVT in calf, may have increased calf pain when you flex toes toward knee.

If notice symptoms, notify caregiver immediately. Risk of developing venous thromboembolism (VTE) and possibly pulmonary embolism, a potentially fatal condition in which portion of blood clot breaks loose and travels to a lung. Symptoms include sudden shortness of breath, chest pain and rapid heart rate. Chances of developing VTE increase if you’re older than 30, you or family have history of blood clots or you’ve recently been on bed rest or been sitting for a long time.

Treating DVT may require pain medication (if leg pain is severe) as well as hospitalization and IV doses of anticoagulant (blood thinner) Heparin to prevent further clot formation. Heparin doses continue at home until birth and are administered by self-injection, pump or IV; then another anticoagulant, Coumadin, is taken orally for 6 weeks.

  1. Venous thrombosis

Promoting Ambulation – Preventing VTE is important. Women who must remain in bed after giving birth are at increased risk for this complication. Antiembolic stockings (TED hose) or a sequential compression device (SCD boots) may be ordered prophylactically. If a woman remains in bed longer than 8 hrs (for postpartum magnesium sulfate therapy for preeclampsia), exercise to promote circulation ni legs is indicated, using following routine:

  • Alternate flexion and extension of the feet
  • Rotate ankles in a circular motion
  • Alternate flexion and extension of legs
  • Press back of knees to bed surface; relax

If woman is susceptible to VTE, she is encouraged to walk about actively for true ambulation and is discouraged from sitting immobile in a chair. Women w varicosities are encouraged to wear support hose. If thrombus suspected, as evidenced by warmth, redness or tenderness in suspected leg, provider should be notified. Meanwhile woman should be confined to bed, w affected limb elevated on pillows.

Promoting Exercise – can begin soon after birth, although woman should be encouraged to start w simple exercises and gradually progress to more strenuous ones. Fig 21-5 illustrates appropriate exercises. Abdominal exercises are postponed until approx. 4-6 wks after cesarean.

Kegels to strengthen muscle tone extremely important, particularly after vaginal birth. Kegels help women regain muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength benefit years later by retaining urinary continence.

Women must learn to perform correctly. Some women perform incorrectly and can increase risk of incontinence, which can occur when inadvertently bearing down on the pelvic floor muscles, thrusting the perineum outward. Health care provider can assess woman’s technique during pelvic exam at her follow up visit.

Promoting Nutrition – during hospital stay, most women have a good appetite and eat well. They may request that family members bring favorite or culturally appropriate foods. Cultural dietary preferences must be respected. This interest in food presents an idea opportunity for nutritional counseling on dietary needs after pregnancy, w specific info related to breastfeeding, preventing constipation and anemia, promoting weight loss and promoting healing and well-being.

A well-balanced diet helps promote healing and health in the postpartum period. The recommended caloric intake for moderately active, nonlactating postpartum woman is 1800-2200 kcal/day. Lactating women need an additional 450-500 kcal/day, which can usually be met w simple adjustments in a normally balanced diet. Women who are underweight, exercise excessively or are breastfeeding more than one infant need additional calories. Dietary intake for lactating women should include 200-300 mg of omega 3 long chain polyunsaturated fatty acids (DHA) so that there is adequate DHA in breast milk. Addition of 1-2 portions of fish w low mercury content provides it. Women on selected vegan diets and those who are poorly nourished may need to take DHA and multivitamin supplements.

Prenatal vitamins may be continued until 6 weeks after birth or until the supply had been used. Iron supplements may be prescribed for women w low hemoglobin and hematocrit levels.

Promoting Normal Bladder and Bowel Patterns – Bladder: mother should void spontaneously within 6-8 hrs after giving birth. First several voidings should be measured to document adequate emptying of the bladder. A volume of at least 150 ml is expected for each voiding. Some women experience difficulty in emptying the bladder, possibly as a result of diminished bladder tone, edema from trauma, or fear of discomfort.

Bowel – after birth, woman can be at risk for constipation related to side effects of medications (opioid analgesics, iron supplements, magnesium sulfate), dehydration, immobility, or presence of episiotomy, perineal lacerations, or hemorrhoids. Woman can be fearful of pain w 1st bowel movement.

Nursing interventions to promote normal bowel elimination include educating woman about measures to prevent constipation, such as ambulation and increasing intake of fluids and fiber. Alerting woman to side effects of medications such as opioid analgesics (decreased gastrointestinal tract motility) can encourage her to implement measures to reduce the risk of constipation. Stool softeners or laxatives may be necessary during early postpartum period. These are used only at direction of health care provider.

Rectal suppositories and enemas should not be administered to women w 3rd or 4th degree perineal lacerations. These measures to treat constipation can be very uncomfortable and can cause hemorrhage or damage to the suture line. They can also predispose woman to infection.

Some moms experiences gas pains; this is more common following cesarean birth. Ambulation or rocking in a rocking chair can stimulate passage of flatus and provide relief. Antiflatulaent medications may be ordered. Mother can avoid foods (legumes, bean broccoli) that tend to produce gas.

Promoting Breastfeeding – ideal time within first 1-2 hrs after birth. Skin to skin asap.

 

Venous Thromboembolic Disorders – VTE results from formation of blood clot or clots inside blood vessel and is caused by inflammation (thrombophlebitis) or partial obstruction of the vessel. 3 thromboembolic conditions are of concern in postpartum period:

  • Superficial venous thrombosis – involvement of the superficial saphenous venous system
  • Deep venous thrombosis (DVT) – occurs most often in the lower extremities; involvement varies but can extend from foot to iliofemoral region
  • Pulmonary embolism (PE)- complication of DVT occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs

Incidence and Etiology – 1/1000 pregnancies. Can occur in any trimester and in postpartum. DVT occurs most often in pregnancy and PE more common in postpartum. Incidence of VTE in postpartum has declined since early ambulation after childbirth has become standard practice. However, PE is a major cause of maternal death. Primary causes of thromboembolic disease are venous stasis and hypercoagulation, both of which are present in pregnancy and continue into postpartum. Cesarean birth nearly doubles the risk for VTE; therefore, routine preoperative placement of pneumatic compression devices is recommended. Other risk factors include operative vaginal birth; history of venous thrombosis, pulmonary embolism, or varicosities; obesity; maternal age greater than 35; multiparity; and smoking.

Clinical Manifestations – Superficial venous thrombosis is the most common form of postpartum thrombophlebitis. It is characterized by pain and tenderness in the lower extremity. Physical examination may reveal warmth; redness; and an enlarged, hardened vein over the site of the thrombosis.

DVT is more common in pregnancy than postpartum and characterized by unilateral leg pain, calf tenderness and swelling. Physical exam may reveal redness and warmth, but women can have a large clot w few symptoms. Positive Homan’s sign may be present, but usually not performed because more objective tests are needed for diagnosis.

Acute pulmonary embolism usually results from dislodged deep vein thrombi. Presenting symptoms are dyspnea and tachypnea (>20 breaths/min). Other signs and symptoms frequently seen include tachycardia (>100 beats/min), apprehension, pleuritic chest pain, cough, hemoptysis, elevated temp, and syncope.

Physical exam is not a sensitive diagnostic indicator for thrombosis. Venous ultrasonography w or w out color Doppler is most commonly used diagnostic test. MRI and d-dimer assays also may be used. With PE, echocardiographic abnormalities may be seen in right ventricular size or function. Pregnancy limits the usefulness of arterial blood gases and oxygen saturation in diagnosis. A ventilation-perfusion scan, spiral computed tomography scan, magnetic resonance angiography, and pulmonary arteriogram may be used for diagnosis.

Medical Management – Superficial venous thrombosis is treated w analgesia (non steroid anti-inflammatory agents), rest w elevation of the affected leg and elastic compression stockings. Heat may also be applied locally.

DVT initially treated w anticoagulant therapy (usually continuous IV heparin), bed rest w affected leg elevated and analgesia. After symptoms have decreased, woman may be fitted with elastic compression stockings to wear when she is allowed to ambulate. She is taught how to put on the stockings before getting out of bed. IV heparin therapy continues for 3-5 days or until symptoms resolve. Oral anticoagulant therapy (warfarin {Coumadin}) is started during this time and will be continued for ~3 months. In long-term therapy the prothrombintime should be monitored at least monthly in an infant and vit K given if necessary.

Acute PE is an emergent situation that requires prompt treatment. Massive pulmonary emboli can lead to pulmonary hypertension and right ventricular dysfunction: if right ventricular dysfunction is present, mortality can be as high as 25%. Immediate treatment of PE is anticoagulant therapy. Continuous IV heparin therapy is used for PE until symptoms have resolved. Intermittent subcutaneous heparin or oral anticoagulant therapy is often continued for up to 6 months.

Nursing Interventions – consists of ongoing assessments: inspecting and palpating the affected area; palpating the peripheral pulses; checking Homan’s sign; and measuring and comparing leg circumferences. Signs of PE, including chest pain, coughing, dyspnea and tachypnea and respiratory status for presence of crackles are also assessed. Lab reports are monitored for prothrombin or partial thromboplastin times. The nurse assess for unusual bleeding. Increased lochia, generalized petechiae, hematuria, or oozing from venipuncture sites should be reported to the provider immediately. Mother and family assessed for level of understanding of diagnosis and ability to cope during unexpected extended period of recovery.

Interventions include explanations and education about diagnosis and treatment. The woman will need assistance w personal care as long as she is on bed rest; the family should be encouraged to participate in the care if that is what she and they wish. While the woman is on bed rest she should be encouraged to change positions frequently but to avoid placing her knees in a sharply flexed position that could cause pooling of blood in lower extremities. She also should be cautioned to avoid rubbing the affected area because this action could cause the clot to dislodge. Heparin and warfarin are administered as ordered, and the physician is notified if clotting times are outside the therapeutic level. If woman is breastfeeding, she is informed that neither heparin nor warfarin is excreted in significant quantities in breast milk. If infant has been discharged, family is encouraged to bring infant for feedings; mother can also express milk to be sent home.

Pain can be managed w a variety of measures. Changing positions, elevating the leg, and applying moist heat may decrease discomfort.   It may be necessary to administer analgesics and anti-inflammatory medications.

The woman is usually discharged home on oral anticoagulants and will need an explanation of the treatment schedule and possible side effects. If subcutaneous injections are to be given, the woman and family are taught how to administer the medication and about site rotation. They should be given info about safe care practices to prevent bleeding and info about safe care practices to prevent bleeding and injury while on anticoagulant therapy (using a soft toothbrush and electric razor). Will need info about follow up care w provider to monitor clotting times and regulate the correct dosage of anticoagulant therapy. The woman should also use a reliable form of contraception if taking warfarin because this medication is considered teratogenic. Oral contraceptives are contraindicated because of the increased risk for thrombosis.

Medications containing aspirin are not given to women on anticoagulant therapy bc it inhibits synthesis of clotting factors and can lead to prolonged clotting time and increased risk for bleeding.

Postpartum Infections – or puerperal infection, is any clinical infection of the genital tract that occurs w in 28 days after miscarriage, induced abortion or birth. Definition in U.S. is presence of fever of 100.4F+ on 2 successive days of first 10 postpartum days (not counting first 24 hrs after birth). In U.S it occurs after approx. 2% of vaginal births and 10-15% of cesarean births. Other common postpartum infections include wound infections, urinary tract infections (UTIs), and respiratory tract infections. Mastitis, or breast infection, should also be considered as a possible diagnosis among breastfeeding mothers, w symptoms such as fever, malaise, flulike symptoms and a sore area in a breast.

Most common infecting organisms are the numerous streptococcal and anaerobic organisms. Staphylococcus aureus, gonococci, coliform bacteria and clostridia are less common but serious pathogenic organisms that can cause puerperal infection. Postpartum infections are more common in women who have concurrent medical or immunosuppressive conditions or who had a cesarean or other operative birth. Intrapartal factors such as prolonged rupture of membranes, prolonged labor, and intrauterine monitoring of uterine contractions or fetal heart rate and pattern increase risk for infection.

Endometritis (infection of lining of uterus) – most common postpartum infection. It usually begins as a localized infection at placental site but can spread to the entire endometrium. Incidence is higher after cesarean birth. Signs of endometritis include fever, increased pulse, chills, anorexia, nausea, fatigue and lethargy, pelvic pain, uterine tenderness and foul smelling, profuse lochia. Leukocytosis and a markedly increased RBC sedimentation rate are typical lab findings of postpartum infections.. Anemia can also be present. Blood cultures or intracervical or intrauterine bacterial cultures (aerobic and anaerobic) should reveal the offending pathogens within 36-48 hrs.

Management – IV broad-spectrum antibiotic therapy (Cephalosporins, penicillins, or clindamycin and gentamicin) and supportive care, including hydration, rest and pain relief. Antibiotic therapy is usually discontinued 24 hrs after woman is asymptomatic. Assessments of lochia, vital signs, and changes in the woman’s condition continue during treatment. Comfort measures depend on symptoms and may include cool compresses, warm blankets, perineal care and sitz baths. Teaching should include side effects of therapy, prevention of spread of infection, signs and symptoms of worsening condition, adherence to treatment plan and need for follow up care. Women may need to be encouraged or assisted to maintain mother-infant interactions and breastfeeding.

 

Predisposing Factors for Postpartum Infection

Preconception or Antepartal Factors:

  • History of previous venous thrombosis, UTI, mastitis, pneumonia
  • Diabetes mellitus
  • Alcoholism
  • Drug abuse
  • Immunosuppression
  • Anemia
  • Malnutrition

Intrapartal Factors:

  • Cesarean birth
  • Operative vaginal birth
  • Prolonged rupture of membranes
  • Chorioamniotis
  • Prolonged labor
  • Bladder catheterization
  • Internal fetal/uterine pressure monitoring
  • Multiple vaginal exams after rupture of membranes
  • Epidural analgesia/anesthesia
  • Retained placental fragments
  • Postpartum hemorrhage
  • Episiotomy or lacerations
  • Hematomas

Womb Infections – common postpartum infections that often develop after mothers are discharged home. Sites of infection include cesarean incision and repaired laceration or episiotomy site. Predisposing factors are similar to those for endometritis. Signs of wound infection include fever, erythema, edema, warmth, tenderness, pain, seropurulent drainage and wound separation.

Management – may combine antibiotic therapy w wound debridement. Wounds can be opened and drained. Nursing care includes frequent assessment and vital signs and wound care. Comfort measures include analgesics, sitz baths, warm compresses and perineal care. Teaching includes good hygiene techniques (changing perineal pads front to back, hand hygiene before and after), self care measures, and signs of worsening conditions to report. Mother is usually discharged to home for self care or home nursing care after treatment is initiated.

Urinary Tract Infections – UTIs occur in 2-4% of postpartum women. Risk factors include urinary catheterization, frequent pelvic exams, regional (epidural or spinal) anesthesia, genital tract injury, history of UTI, and cesarean birth. Signs and symptoms include dysuria, frequency and urgency, low-grade fever, urinary retention, hematuria, and pyuria. Costovertebral angle tenderness or flank pain can indicate upper UTI. Most common infecting organism is Escherichia coli, although other gram-negative aerobic bacilli can cause UTIs.

Management – antibiotic therapy, analgesia and hydration. Postpartum women usually treated on outpatient basis; therefore, teaching should include instructions on how to monitor temp, bladder function, and appearance of urine. Should be taught potential complications and importance of taking all antibiotics as prescribed. Other suggestions for preventions include proper perineal care, wiping from front to back after urinating or having a bowel movement and increasing fluid intake. Cranberries and juice have been widely used for prevention and treatment, authors of meta-analysis of 24 studies say evidence to prevent UTIs is small and thus do not recommend.

 

Infections – risk of acquiring a serious infection during pregnancy is low, but sometimes infectious disease can affect pregnancy/harm baby. potential risks depend on organism (virus, bacterium or spore), whether you have antibodies to organism from prior exposure, whether disease is treatable, when during pregnancy you acquired infection. Even if you get infection during pregnancy, baby might not become infected and even if he does, he may not be harmed.

  1. Infections during pregnancy

Risk Reduction Measures (STIs) – counseling regarding risk-reduction practices, including knowledge of partner, reduction in # of partners, low risk sex, avoiding exchange of body fluids and vaccinations.

No aspect is more important than knowing one’s partner. Reducing # of partners and avoiding partners who have had many sexual partners decreases chances. Deciding not to have sex with casual acquaintances may be helpful. Discussing each new partner’s previous sex history and exposure to STIs augments other efforts to reduce risk; however, sex partner may not always be truthful about history. Women must be informed that practicing risk-reduction measures is always advisable, even when partners insist otherwise. Crucially important is whether male partners resist or accept wearing condoms. Crucial when women not sure about history. Women should be cautioned about making decisions based on appearances and unfounded assumptions such as:

  • Single people have many partners and risky practices
  • Older people have few partners and infrequent sexual encounters
  • Sexually experienced people know how to use risk-reduction measures
  • Married people are heterosexual, low risk and monogamous
  • People who look healthy are healthy
  • People with good jobs do not use drugs

Sexually active people may benefit from examining partner for lesions, sores, ulcerations, rashes, redness, discharge, swelling and odor before initiating sexual activity. Teach women about low risk practices and which to avoid.

Physical barrier promoted for prevention of HIV and other STIS is condom (male and female). Info to be discussed includes importance of using latex or plastic male condoms rather than natural skin condoms for STI protection. Use condom with every encounter – only once, not expired and handle carefully without damaging with fingernails, teeth or other sharp objects. Store away from high heat.

Female condom – lubricated polyurethane sheath w a ring on each end, one that is inserted into vagina and other covering labia – has shown in lab studies to be an effective mechanical barrier to viruses, including HIV. Although no clinical studies have been complete to evaluate the efficacy of female condoms in protecting against STIs, lab studies have demonstrated that polyurethane can block smaller viruses such as herpes virus and HIV. CDC state when used correctly and consistently, it may reduce STI risk and recommended its use when a male condom can’t be properly used. What is important and should be stressed by nurses is consistent use of condoms for every act of sex when there is possibility of transmission of disease.

Despite concern about potential for cervicovaginal epithelial disruption w nonoxynol-9 (N-9) based spermicides, interest in vaginally applied chemical barriers that provide dual contraception and protection against bacterial STIs remains. Evidence has shown, however, that vaginal spermicides do not protect against certain STIs such as cervical gonorrhea and chlamydia and are not effective in preventing HIV infection. Condoms lubricated with N-9 are not recommended for prevention of HIV and STIs.

Key issue in condom use as a preventative strategy is to stress to women that in sexual encounters men must comply w a woman’s suggest or request that they use one. Must be renegotiated w every sexual contact. Some women fear rejection and abandonment, conflict, potential violence or loss of economic support if they suggest use. For many individuals, they are symbols of extra-relationship activity. Introduction into a long term relationship in which one wasn’t used previously threatens trust.

Nurses must suggest strategies to enhance a woman’s negotiation and communication skills. Can suggest talking about it at time other than sexual activity. Role-playing possible partner reactions can be helpful. Asking a woman who appears uncomfortable to rehearse might help. Can say “I need to talk with you about something that’s important to both of us. It’s hard for me and I feel embarrassed, but I think we need to talk about reducing risk during sex”. If women able to sort out feelings before may be more comfortable and in control of situation. Women can be reassured its natural to be uncomfortable and hardest part is getting started. Nurses should help clients clarify what they will do and what they won’t sexually because it will be easier to discuss with partners if thought about what to say.

Many women do not anticipate or prepare for sexual activity in advance; embarrassment or discomfort in purchasing condoms may prevent some women from using them. Cultural barriers may also impede use. Sometimes talking about condom use may imply women is available or seeking for sex. Society sometimes views a woman who carries a condom as overprepared, possibly oversexed and wiling to have sex w any man.

Preexposure vaccination is an effective method for prevention fo some STIs such as Hep B and HPV. Hep B vaccine recommended for women at high risk for STIs. 2 HPV vaccines available for females aged 9-26 to prevent cervical precancer and cancer: the quadrivalent (HPV types 6, 11, 16, and 18) HPV vaccine (Gardasil) and bivalent (HPV types 16 and 18) HPV vaccine (Cervarix). Gardasil also prevents genital warts. Routine vaccination of females ages 11 or 12 is recommended, as is catch up vaccinations for females 13-26. Also approved for males 9-26.

 

Selected STI

Bacteria: chlamydia, gonorrhea, syphilis, chancroid, lymphogranuloma venereum

Viruses: HIV, Herpes simplex 1&2, Cytomegalovirus, Hepatitis A&B, HPV

Protozoa: Trichomoniasis

Parasites: Pediculosis, Scabies

Box 7-2 Assessing STIs and HIV risk Behaviors using the 5 P’s: Partners, Prevention of Pregnancy, Protecting from STIs, Practices and Past History of STIs

  1. Partners
    1. Do you have sex with men, women or both?
    2. In the past 2 months, how many partners have you had sex with?
    3. In the past 12 months, how many partners have you had sex with?
    4. Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you?
  2. Prevention of Pregnancy
    1. What are you doing to prevent pregnancy?
  3. Protection from STIs
    1. What do you do to protect yourself from STIs and HIV?
  4. Practices
    1. To understand your risk for STIs, I need you to understand the kind of sex you have had recently
    2. Have you had vaginal sx, meaning penis in vagina sex. If yes, do you use condoms? Never, sometimes or always?
    3. Have you had anal sex – penis in rectum/anus. If yes, do you use condoms: never, sometimes or always?
    4. Have you had oral sex- mouth on penis/vagina?
    5. For condom answers – If never, why not? If sometimes – in what situations or w whom do you use?
  5. Past History of STIs
    1. Have you ever had an STI?
    2. Have any of your partners had an STI?
    3. Additional questions to identify HIV and viral hepatitis: have you or any of your partners ever injected drugs? Have any of your partners exchanged money or drugs for sex? Is there anything else about your sexual practices that I need to know about?

 

Risk-Reduction Practices:

Safest: Abstinence, self-masturbation; monogamous and tested negative for HIV and other STIs; hugging, massage, touching (no break in skin)), dry kissing, mutual masturbation without contact w semen or vaginal secretions and no broken skin, drug abstinence, sexual fantasy, erotic conversation, books movies, erotic bathing, showering, eroticizing feet, fingers, buttocks, abdomen, ears

Low But Potential Risk: wet kissing (no break in skin), vaginal intercourse w condom; anal intercourse with condom; monogamous (both partners and no high risk activities) but not tested for HIV or other STIs; oral sex w woman wearing female condom; oral sex w man wearing condom; mutual masturbation without contact w semen or vaginal secretions; healthy intact skin or use of latex or plastic barrier; urine contact w intact skin

High Risk (Unsafe): unprotected anal intercourse; unprotected vaginal intercourse; oral-anal contact; multiple sexual partners – no HIV or STI testing; any sex (fisting, rough vaginal or anal intercourse, rape) that causes tissue damage or bleeding; oral sex on man or woman w/out latex or plastic barrier; sharing sex toys, douche equipment; sharing needles; blood contact, including menstrual blood

 

STIs and Drug Therapies for Women

Disease/ Nonpregnant (13-17)/ Nonpregnant (>17)/ Pregnant / Lactating

  • Chlamydia – azithromycin, 1 g orally once or doxycycline, 100 mg orally for 7 days/ same/ azithromycin, 1 g orally once or amoxicillin, 500 mg orally 7 days / same as pregnant
  • Gonorrhea – ceftriaxone, 125 mg IM once (those who weight >45 kg can be treated w any regimen recommended for adults) plus treatment for chlamydia above/ ceftriaxone, 250 mg IM once plus treatment for chlamydia above/ same as previous/ same as previous
  • Syphilis: primary, secondary, early latent disease – benzathine penicillin G, 2.4 m units, IM once/ same/ some experts recommended a 2nd dose 1 wk later/ same as nonpregnant
  • Syphilis: late-latent or unknown duration disease – benzathine penicillin G, 7.2 M units ottal, administered as 3 doses, 2.4 m units each at 1 wk intervals; if penicillin allergy – doxycycline, 100 mg orally for 14 days or tetracycline, 400 mg orally for 14 days/ same/ no alternative sto pencilin in pregnancy; should be desensitized and treated w penicillin/ no late-latent for lactating
  • HPV – client: podofilox, .5% solution or gel to wart bid for 3 days followed by 4 day rest for 4 cycles or imiquimod, 5% cream at bedtime 3x week for 16 wk or sinacatechins 15% oint for 16 wk/ same/ no client applied for pregnant or lactating
  • HPV – provider: cryotherapy w liquid nitrogen or cryoprobe or podophylin resin, 10-25% in tincture of benzoin compound weekly (wash off in 1-4 hr) repeat weekly as necessary or trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 89-90% weekly/ same/ same plus imiquimod, podophylin (Podocon-25), sinecatechins and podofilox should not be used in pregnancy/ same

 

Sexually Transmitted Bacterial Infections

Chlamydia – Chlamydia trachomatis is the most commonly reported STI in American women. In 2011, >1.4 M cases reported; rate of infection was more than 2.5x the rate for men. Infections often silent and highly destructive; their sequelae and complications can be very serious. In women, difficult to diagnose. Symptoms non specific and organism is expensive to culture. Early ID important because untreated often leads to acute salpingitis or pelvic inflammatory disease. PID is most serious complication and past infections associated w increased risk of ectopic pregnancy and tubal factor infertility. Chlamydial infection of cervix causes inflammation, resulting in microscopic cervical ulcerations, and may increase risk of acquiring HIV. More than half infants born to mothers with chlamydia will develop conjunctivitis or pneumonia after perinatal exposure to mother’s infected cervix. Most common infectious cause of ophthalmia neonatorum. Neonatal ocular prophylaxis w silver nitrate or antibiotic ointment does not prevent perinatal transmission nor does it adequately treat infection. Sexually active women 15-24 have highest rates of infection, w women 18-20 having highest rates. 2011- rates highest in black women at 7x rate of white women. American Indian, Alaska Native, and Hispanic women also had higher rates than white women. Women >30 have lowest rate of infection. Risky behaviors, including multiple partners and nonuse of barrier methods of birth control increase risk. Lower socioeconomic status may be risk factor.

Nurse should screen risk factors and presence of symptoms. CDC recommends screening of asymptomatic women at high risk. Yearly screening of all sexually active adolescents, women 20-25 and high risk women >25. All women w 2+ risk factors should be cultured. All pregnant women should have cervical cultures at first prenatal visit. Screening late in 3rd trimester (36 weeks) if woman previously positive; or if younger than 25 years, has new sex partner or multiple sex partner.

Some women experience spotting or postcoital bleeding, mucoid or purulent cervical discharge or dysuria. Bleeding results from inflammation and erosion of cervical columnar epithelium.

Lab diagnosis by culture (expensive and labor intensive), deoxyribonuclein acid (DNA) probe (relatively less expensive but less sensitive), enzyme immunoassay (relatively less expensive but less sensitive) and nucleic acid amplification test (NAATs) (expensive but higher sensitivity). Special culture media and proper handling of specimens important , so nurse should always know what is required in individual practice site.

Culture testing not always available, primarily because of expense.

Management – treatment of urethral, cervical and rectal chlamydial infections – azithromycin or doxycycline. Azithromycin often prescribed when compliance may be a problem, because only 1 dose needed; however, expense a concern. If woman pregnant, azithromycin or amoxicillin is used. Pregnant women should be retested in 3 weeks to determine if treatment was effective; if at high risk for reinfection the pregnant woman should be retested in 3rd trimester. Women w chlamydial infection and infected w HIV should be treated w same regimen as those not infected w HIV.

Because often asymptomatic, woman should be cautioned to take all medication prescribed. All exposed partners should be treated.

Gonorrhea- prob oldest communicable disease in U.S. and second to chlamydia in reported cases. 2012 – >300k cases reported in U.S. incidence of drug-resistant cases, in particular penicillinase-producing Neisseria gonorrhoeae (PPNG) is increasing dramatically. Only a single class of antibiotics now meets standard for treatment – the cephalosporins.

Caused by aerobic gram-negative diploccocus, N. Gonorrhoeae. Almost exclusively transmitted via sexual contact. Principal means is genital to genital contact; however also spread by oral to genital and anal to genital. Infection can spread in females from vagina to rectum. Age probably most important risk factor. Highest reported rates among sexually active teenagers, young adults, and blacks. 2012- highest rates 15-24 and rate in blacks was 15x higher. American Indian, Alaska Native and Hispanic rates also higher. Women often asymptomatic, 1/3 of infections going unnoticed. When symptoms present, often less specific that symptoms in men. Women may have a purulent endocervical discharge, but discharge is usually minimal or absent. Menstrual irregularities may be presenting symptom. Or may complain of pain – chronic or acute severe pelvic or lower abdominal pain or longer, more painful menses. Infrequently, dysuria, vague abdominal pain or low backache prompts woman to seek care. Gonococcal rectal infection may occur in women after anal intercourse. Individuals w rectal gonorrhea may be completely asymptomatic or, conversely, have severe symptoms w profuse purulent anal discharge, rectal pain, and blood in stool. Rectal itching, fullness, pressure and pain also common symptoms, as is diarrhea. A diffuse vaginitis w vulvitis is most common form of honococcal infection in prepubertal girls. May be few signs of infections or vaginal discharge, dysuria, and swollen, reddened labia may be present.

Gonococcal infections in pregnancy can affect mom and fetus. In women w cervical gonorrhea, salpingitis may develop in 1st trimester. Perinatal complications of gonococcal infection include premature rupture of membranes, preterm birth, chorioamnionitis, neonatal sepsis, intrauterine growth restriction, and maternal postpartum sepsis. Amniotic infection syndrome manifested by placental, fetal and umbilical cord inflammation after premature rupture of membranes may result from gonorrhea infections during pregnancy. Ophthalmia neonatorum, the most common manifestation of neonatal gonococcal infections, is highly contagious and, if untreated, may lead to blindness of newborn.

Screening/Diagnosis – because often asymptomatic, recommends screen all women at risk. All pregnant women should be screened at 1st prenatal visit and infected women and those not infected but identified w risky behaviors should be rescreened at 36 weeks. Gonococcal infection cannot be diagnosed reliably by clinical signs and symptoms alone. Individuals may have classic symptoms, vague symptoms that can be attributed to a number of conditions or no symptoms at all. Cultures w selective media are considered the gold standard for diagnosis.

Specific diagnoses of infection w N. gonorrhoeae can be performed by testing endocervical, vaginal or urine specimens. Culture and nonculture tests (nucleic acid hybridization tests and NAATs) are available for detection of genitourinary infection. Cultures should be obtained from endocervix, rectum, and when indicated, the pharynx. Thayer-Martin cultures are recommended to diagnoses gonorrhea in women. NAATs allow testing of widest variety of specimen types including endocervical swabs, vaginal swabs and urine. Because coinfection is common, any woman suspected of having gonorrhea should have a chlamydial culture and serologic test for syphilis if 1 had not been done in past 2 months.

Management – cure is usually rapid w appropriate antibiotic therapy. Single-dose efficacy is a major consideration in selecting an antibiotic regimen. Another important consideration is high % of women w coexisting chlamydial infections. Treatment of choice for uncomplicated uretheral, endocervical and rectal infections in pregnant and nonpregnant women is ceftriaxone. CDC recommends concomitant treatment for chlaymydia. Test of cure in 3-4 weeks after treatment is not recommended for pregnant women. All women w both gonorrhea and syphilis should be treated for syphilis according to CDC guidelines.

Gonorrhea is a highly communicable disease. Important to notify partners if woman is diagnoses. Recent (past 30 days) should be examined, culture and treated w appropriate regimens. Most treatment failures result from reinfection. Women must be informed of this, as well as consequences of reinfection in terms of chronicity, complications, and potential infertility. Women counseled to use condoms. All clients should be offered confidential counseling and testing for HIV.

Gonorrhea is a reportable communicable disease. Health care providers legally responsible for reporting all cases to health authorities, usually local health department in county. Women should be informed that case will be reported told why and informed of possibility of being contacted by health department epidemiologist.

Syphilis – one of the earliest described STIs caused by Treponema pallidum a motile spirochete. Transmission thought to be entry in subcutaneous tissue through microscopic abrasions that can occur during sexual intercourse. Disease also transmitted via kissing, biting or oral-genital sex. Transplacental transmission can occur at any time during pregnancy; degree of risk related to quantity of spirochetes in maternal bloodstream.

2012 – 50k cases in U.S. includes 15k cases of primary and secondary syphilis. Rates or primary and secondary highest ages 20-24. Rates highest in black women.

Complex disease that can lead to serious systemic disease and even death when untreated. Infection manifests itself in distinct stages w different symptoms and clinical manifestations. Primary syphilis characterized by primary lesion, the chancre, that appears 5-90 days after infection. Lesions begins as painless papule at sit of inoculation and then erodes to form a nontender, shallow, indurate, clean ulcer several mm to cm in size.

Secondary syphilis occurs 6 wks – 6 months after appearance of chancre and characterized by wide-spread, symmetric maculopapular rash on palms and soles and generalized lymphadenopathy. Infected individual also may experience fever, headache, and malaise. Condylomata lata (broad, painless, pink-gray wartlike infectious lesions) may develop on vulva, perineum, or anus. If woman untreated, she enters a latent phase that is asymptomatic for majority of individuals. Latent infections are those that lack clinical manifestations but are detected by serologic testing. If infection acquire in preceding year, infection termed early latent infection. If left untreated, tertiary syphilis will develop in about 1/3 of these women. Neurologic, cardiovascular, musculoskeletal, or multiorgan system complications can develop in 3rd stage.

 

Ways to Avoid Getting Sick – best way to prevent complications is to avoid getting sick

  • Wash hands several times a day, especially before eating and after using toilet. Germs live on doorknobs, handrails, phones, hands and other surfaces.
  • Stay away from sick people, especially if vaccinations aren’t up to date
  • Update vaccinations or have immune status checked before pregnancy. Chicken pox (Varicella zoster), measles, mumps and rubella or German measles (MMR) not recommended in pregnancy or months before conception. If received MMR as a child, may be still immune but effectiveness of some vaccines such as rubella, diminish
  • Eat safe foods. Wash fruits and veggies. Adequately cook meats and other foods. Thoroughly clean food prep surfaces

Sexually Transmitted Infections (STI) – previously called STDs; can cause problems during pregnancy, but if treated early, risks to baby are minimal. If had multiple partners, at greater risk for chlamydia, gonorrhea, genital herpes, Hep B, HIV, HPV, syphilis and trichomoniasis. If had symptoms – genital sores, abnormal discharge or discomfort/difficulty with urination, see caregiver.

Group B Streptococcus (GBS) – 10-30% of pregnant women are carriers which means GBS bacteria is present ni body but don’t have signs of infection. Without treatment, 1/200 newborns will develop a GBS infection, which can be life threatening. If moms receive antibiotic treatment during labor, babies risk of infection drops to 1/4000.

Guidelines for screening women between 35-37 weeks by swabbing vagina and anus and having secretions cultured in a lab. If she is a GBS carrier, caregiver treats her with antibiotics during labor and watches her baby closely for signs of infection.

Women with following circumstances may receive antibiotics during labor without prior screening: UTI caused by GBS during pregnancy (even if received antibiotics), previous pregnancy with baby who had severe GBS. If a woman hasn’t been tested or results of culture aren’t known when labor begins, a woman receives antibiotics if she has any of following risk factors: preterm labor (before 37th week), rupture membranes for more than 18 hours before labor begins, fever of 100.4F (38C) or higher

Antibiotic treatment of all pregnancy GBS carriers is controversial. Although only a few develop an infection, all babies are exposes to possible side effects of antibiotics such as allergic reaction, creation of drug-resistant bacteria and yeast infection after birth. Even so, most GBS carriers choose antibiotic treatment during labor to reduce risk of GBS in baby.

Bladder and Vaginal Infections – increase risk of preterm labor. Symptoms of bladder infection or UTI include frequent urination, urgency to urinate, blood in urine, and pain, especially at end of urination. Symptoms of vaginal infection include vaginal discomfort or itching and foul-smelling discharge. Normal to have thin, milk smelling and whitish vaginal discharge.

Listeriosis – form of food poisoning that can harm baby. While rare, affects pregnant woman 20x more than others. Bacteria is in unpasteurized dairy products, raw or undercooked meats and fish, and in contaminated soil and water. Avoid eating unpasteurized milk and soft cheeses during pregnancy. Don’t eat meat, poultry, eggs or seafood that isn’t cooked thoroughly. Wash produce before eating and carefully wash food prep surfaces and utensils.

Toxoplasmosis – cats are the most common carriers, especially outdoor cats that eat rats, mice and other raw meet. Passes in its feces and can transmit from hands to mouth if you don’t wash hands after handling cats or gardening. Can also ingest from eating raw/undercooked meat/unwashed root veggies. May be immune if been around cats for years, but tests for immunity unreliable and not recommended. If get it for first time during 1st trimester, may cause congenital defects or miscarriage. If infected 3rd trimester, baby may be born with infection. Can treat with antibiotics, but prevention is best treatment. Wash hands after touching cat, have someone else change litter and wear gardening gloves. Cook meat well and wash veggies thoroughly.

Infections during pregnancy chart (birth defects/preterm labor/illness in baby)

  • Bacterial vaginosis (BV) – preterm labor; problems result from prematurity
  • Chicken pox (Varicella zoster) – birth defects, illness in baby – slight risk of infection affecting one or all of baby’s organs
  • Chlamydia trachomatis – birth defects, illness in baby; baby not affected before birth, but may have eye infection or pneumonia after birth
  • Cytomegalovirus (CMV)– birth defects, illness in baby; risk of brain damage or hearing loss. About 10% of babies affected when mother is first infected in 1st trimester
  • Fifth disease (parovirus B19) – illness in baby; may cause sever anemia and related problems for baby
  • Gonorrhea (Neisseria gonorrhea) – illness in baby; if baby is infected during birth, infection might cause severe eye infection that may cause blindness
  • Group b streptococcus (GBS) – preterm labor, illness in baby; if baby infected at birth, infection may cause severe disease or death
  • Hep B (HBV) or Hep C (HCV) – illness in baby; if baby is infected at birth and untreated, she’s at hish risk of becoming a HBV carrier, but at low risk of becoming a HCV carrier
  • Herpes simplex virus (HSV) – illness in baby; risk of infection is highest when mom has her first outbreak of genital herpes in pregnancy. Any recurrent infection at birth may affect baby. Treatment of outbreaks reduces chances of infection
  • Human immondeficiency virus (HIV) – illness in baby; treatment of mother can greatly reduce risk of baby’s acquiring HIV during pregnancy or at birth
  • Human papillomavirus (HPV) – low risk of baby’s acquiring HPV during pregnancy or at birth. May cause genital warts or cervical cancer later in child’s life
  • Listeriosis (listeria monocytogenes) – preterm labor, illness in baby; may cause miscarriage or infection in baby after birth
  • Lyme disease – bacteria from a tick bite can cross placenta. Risks are unknown, but may cause miscarriage or stillbirth.
  • Mumps (paramyxovirus) – illness in baby; although connection is unconfirmed, infection may cause miscarriage. May cause infection in baby after birth
  • Measles – illness in baby; may cause infection in baby after birth
  • Periodontal disease (gum disease) – preterm labor; severe gingivitis greatly increases risk of preterm birth
  • Rubella (German measles) – birth defects, preterm labor, illness in baby; when baby is infected in 1st half of pregnancy, infection increases risk of problems with hearing, vision, heart function or brain development
  • Syphilis (treponema pallidum) – birth defects, illness in baby; possible problems with baby’s eyes, skin, heart, bones, and nervous system. May cause death.
  • Toxoplasmosis (toxoplasma gondii) – birth defects, illness in baby – possible effects on all of baby’s organs; may cause death. Problems are more severe if mother is first infected in first half of pregnancy
  • Trichomoniasis – problems result from prematurity. Infected mothers often have other infections
  • Yeast (Candidaiasis) – illness in baby; exposure may occur with vaginal birth, but infection is rare. Chances of infection on mother’s nipples or in baby’s mouth (thrush) increase if mother had antibiotics near time of birth

 

  1. Sexually transmitted infections
  2. Group B streptococcus
  3. Bladder and vaginal infections
  4. Listeriosis
  5. Toxoplasmosis
  6. Diabetes mellitus

 

Diabetes Mellitus and Gestation Diabetes Mellitus – aka DM or simply diabetes occurs when someone has trouble making or using insulin, a hormone that helps glucose (sugar) pass into cells for the body to use as an energy source. 2 types: type 1 – body stops making insulin. Type 2 – body uses insulin ineffectively. Without insulin, blood glucose levels rise dramatically and glucose passes into urine. Can cause serious problems in pregnancy.

Woman with DM needs to balance her medications with her activity level and diet. May need to adjust insulin dose or begin taking injections to control blood glucose levels. Improves chances of carrying healthy baby to term if she controls blood glucose levels before and during pregnancy.

Gestational diabetes mellitus (GDM) develops or is first recognized in pregnancy and affects 3-5% of women. Human placental lactogen (HPL) diminishes the effect of insulin and allows more glucose for baby’s growth. In some women, their response to this pregnancy hormone is out of balance, leading to excessively high blood glucose levels.

Early detection and appropriate treatment of GDM can help prevent problems such as increased chances of UTI, overly large baby, preterm birth, stillbirth and newborn with hypoglycemia (low blood sugar), jaundice or breathing difficulties.

Some caregivers use urine tests to screen for glucose in early pregnancy. Most use blood tests to screen for GDM between 24th and 28th week. Risk factors include women who have family members with DM, obese women, and those of Hispanic or African descent.

If blood test is positive for high glucose levels, caregiver will order a glucose tolerance test (GTT) to confirm diagnosis, a process that requires blood testes every hour for 3 hours.

Treatment includes a special diet, exercise, and in some cases oral medications or insulin injections. If caregiver suspects baby is overly large or that placenta circulation is affected, her or she may induce your labor near term. After birth, blood glucose levels will probably return to normal levels; however about half of women develop type 2 DM later in life.

  1. Rh blood incompatibility

 

Rh Incompatibility – or isoimmunization occurs when Rh-negative mom has Rh-positive fetus who inherits dominant Rh-positive gene from father. If mom is Rh-neg and father is Rh-pos and homozygous for Rh factor, all offspring will be Rh positive. If father is heterozygous for factor, 50% chance each will be Rh neg. an Rh-neg fetus is in no danger because it has the same Rh factor as mom. Rh-neg fetus w Rh positive mom also in no danger. Only Rh-pos fetus of Rh-neg mom at risk. 10-15% of all Caucasian couples and 5% of African-American couples have Rh incompatibility. Rare in Asian couples due to high incidence of ABO incompatibility, which is protective against Rh isoimmuication because of rapid destruction of fetal RBCs, which prevents Rh antigen exposure and maternal antibody production.

Pathogenesis of Rh incompatibility is as follows. Hematopoiesis (Formation, production, and maintenance of blood cells) in fetus is well established by 9th week of gestation. When fetal RBCs that contain Rh antigen pass through placenta into maternal circulation of Rh-neg woman the maternal immune system produces antibodies against the foreign fetal antigens. Process of antibody formation called maternal sensitization. Sensitization can occur during pregnancy, birth, miscarriage or induced abortion, amniocentesis, external cephalic version or trauma. Usually rh-neg women become sensitized in their first pregnancy w an Rh positive fetus but do not produce enough antibodies to cause lysis (destruction ) of fetal blood cells. During subsequent pregnancies, antibodies form in response to repeated contact w the antigen from the fetal blood and lysis of fetal RBCs results. The overall incidence of isoimmunization is less than 1%. Multi0ple gestation, placental abruption, placenta previa, manual removal of placenta, and cesarean birth increase incidence of transplacental hemorrhage and risk of isoimmunization.

Severe Rh incompatibility results in marked fetal hemolytic anemia because fetal erythrocytes are destroyed by maternal Rh-positive antibodies. Although placenta usually clears the bilirubin resulting from RBC breakdown, in extreme cases fetal bilirubin levels increase. This results in fetal jaundice, also known as icterus gravis.

The fetus compensates for the anemia by producing large numbers of immature erythrocytes to replace those hemolyzed, thus the name for this condition: erythroblastosis fetalis. In hydrops fetalis, the most severe form of this disease, the fetus has marked anemia, cardiac decompensation, cardiomegaly, and hepatosplenomegaly. Hypoxia results from the severe anemia. In addition, because of decreased intravascular oncotic pressure, fluid leaks out of the intravascular space. This results in generalized edema, as well as effusions into the periotoneal (ascites), pericardial and pleural (hydrothorax) spaces. Placenta is often edematous, which, along w edematous fetus, can cause uterine rupture.

Intrauterine or early neonatal death can occur as a result of hydrops fetalis, although intrauterine transfusions and early birth of the fetus can help to avert this. Intrauterine transfusion involves the infusion of Rh neg, type O blood into the umbilical vein. The frequency of intrauterine transfusions varies according to institution protocol and fetal hydropic status, but can be as often as every 2 weeks until fetus reaches pulmonary maturity at approx. 37-38 weeks gestation. Studies of uses of intrauterine transfusions have demonstrated a high survival rate and low risk of disabilities in the surviving infant.

ABO Incompatibility – most common cause of hemolytic disease in newborn, although anemia that results is usually mild. ABO maternal blood group incompatibility occurs in almost 25% of infants; however, only ~1-5% have clinical manifestations. Occurs if fetal blood type is A,B, or AB and maternal type if O. Occurs rarely in infants w type B blood born to moms w type A blood. The incompatibility arises because naturally occurring anti-A and anti-B antibodies are transferred across the placenta to fetus. Unlike situation that pertains to Rh incompatibility, first-born infants can be affected because mothers with type O blood already have anti-A and anti-B antibodies in their blood. Such a newborn can have a weakly positive direct Coomb’s test (also referred to as a direct antiglobulin test (DAT)). The cord bilirubin level usually is less than 4 mg/dl and any resulting hyperbilirubinemia usually can be treated w phototherapy. Exchange transfusion are required only occasionally. Although ABO incompatibility is a common cause of hyperbilirubinemia, it rarely precipitates significant anemia resulting from the hemolysis of RBCs.

Other Causes of Hemolytic Jaundice – not scope of textbook to discuss many potential causes of hemolytic jaundice in childhood. Among African-American and people of Mediterranean heritage there is a high incidence of G6PD deficiency. Because it’s a sex-linked disease, male offspring are affected more often than females. A deficiency of a red blood cell enzyme in combination w exposure to an oxidant stressor (such as sepsis) results in hemolysis and a decreased RBC life. The increase in the destruction of RBCs overwhelms the immature neonatal liver’s ability to conjugate the indirect bilirubin. Treatment is the same as for any newborn w rapidly rising serum bilirubin levels. Other metabolic and inherited conditions that increase hemolysis and can cause jaundice in the infant include galactosemia, Crigler-Najjar disease and hypothyroidism.

Acute Bilirubin Encephalopathy – goal of care for infant w hyperbilirubinemia is to prevent acute bilirubin encephalopathy (ABE) and kernicterus. Acute bilirubin encephalopathy is caused by deposition of bilirubin in brain, esp w/in basal ganglia, the cerebellum and hippocampus. Normally bilirubin doesn’t cause harm because its bound to albumin and carried to the liver to undergo conjugation. However, once albumin binding sites are saturated, the bilirubin circulates as unconjugated (indirect) bilirubin, which is highly lipid soluble and capable of crossing the blood-brain barrier. Circulation of unconjugated bilirubin can reach toxic levels and become deposited in the basal ganglia, resulting in the yellowish staining of the brain tissue and the necrosis of neurons.

Acute bilirubin encephalopathy, which can develop in newborns with no apparent signs of clinical jaundice, is directly related to the total serum bilirubin level, although these levels alone do not predict the risk of brain injury. In a term infant, a serum bilirubin level of 25 mg/dl is considered the upper limit, beyond which the risk for acute bilirubin encephalopathy increases. However, the condition can occur at much lower levels in premature infants or infants with other complications.

Some of the perinatal events that increase the likelihood of acute bilirubin encephalopathy, even at these lower bilirubin levels, include hypoxia, asphyxia, acidosis, hypothermia, hypoglycemia, sepsis, treatment with certain medications, and hypoalbuminemia. In essence, any condition that interferes with the conjugation of bilirubin or competes for albumin-binding sites increases the risk that unconjugated bilirubin can pass through the blood-brain barrier and cause damage to the CNS.

Acute bilirubin encephalopathy is associated w acute and long-term signs of neurologic damage. The clinical manifestations typically appear between 2-6 days after birth and go through several phases as the disease progresses. During the 1st phase the newborn is hypotonic and lethargic and has a poor suck and depressed or absent Moro reflex. These subtler signs are followed by the appearance of a high-pitched cry, opisthotonos (severe muscle spasm that causes the back to arch acutely), spasticity, hyperreflexia, and fever. If allowed to progress to the 3rd phase, the neonate will demonstrate a shrill cry, apnea, deep stupor to coma, seizures, and hearing and visual disturbances. Death can occur from cardiovascular collapse.

About half of affected infants survive, although they often have permanent sequelae including extrapyramidal movement disorders (esp dystonia and athetosis), gaze abnormalities (esp upward gaze), auditory disturbances (esp sensorineural hearing loss), cognitive impairment, and enamel dysplasia of the deciduous teeth. Movement abnormalities and auditory disturbances are almost always present. Kernicterus is the irreversible, chronic consequence of bilirubin toxicity. It develops in approx. 30% of infants w untreated hemolytic disease and hyperbilirubinemia greater than or equal to 25-30 mg/dl. Classic symptoms of kernicterus include severe dystonia w or w out athetosis, deafness or severe hearing impairment, impaired oculomotor function, and dental enamel dysplasia of the deciduous teeth. Over the 1st year of life a baby demonstrates the characteristic findings of hypotonia, active deep tendon reflexes, persistent tonic neck reflex, upward gaze, sensorineural hearing loss, and difficulty meeting developmental milestones. Severe cognitive impairment and spastic quadriplegia often occur. Treatment is supportive.

Care Management – important to determine blood type and Rh factor of prenatal woman prenatally. Early ID of Rh-negative woman is critical, and care must be taken to prevent sensitization. Nurse must obtain thorough history to assess for events that could have caused the woman to develop antibodies to Rh factor. Such events include 1) previous pregnancy w Rh-positive fetus 2) transfusion w Rh-positive blood, which causes immediate sensitization; 3) miscarriage or induced abortion after 8+ weeks gestation 4) amniocentesis performed for any reason 5) premature separation of placenta 6) external version and 7) trauma.

Because hematopoiesis is well developed in the fetus by the 9th week gestation, a woman who has had a miscarriage or induced abortion after this time or has previously given birth may have been inoculated w fetal blood at the time of placental separation. During amniocentesis the needle can cause localized damage to the single layer of cells that separates the maternal and fetal circulation in the placenta, thereby allowing fetal RBs to enter the maternal circulation.

If any of these events has occurred, nurse checks woman’s record to determine whether she has received Rh immune globulin, such as RhoGAM (WinGAM), which is a commercial preparation of passive antibodies against the Rh factor. This injection of anti-Rh antibodies destroys any fetal RBCs in the maternal circulation and blocks the maternal antibody production. Rh immune globulin is 90% effective in preventing sensitization. It is recommended that it be given to an Rh-negative mother at 28 weeks gestation; within 72 hrs after delivery; after an invasive procedure such as amniocentesis, CVS, or PUBS; and anytime there is a risk of fetal-maternal hemorrhage. Also recommended after induced abortion, miscarriage and ectopic pregnancy.

At first prenatal visit of Rh-neg woman w fetus who may be Rh positive, and indirect Coombs’ test should be done to determine whether she has antibodies to the Rh antigen. Maternal blood serum is mixed w Rh-positive RBCs. If Rh-positive RBCs agglutinate or clump, this indicates that maternal antibodies are present or that mother has been sensitized. The dilution of the specimen of blood at which clumping occurs determines the titer, or level, or maternal antibodies. Titer indicates degree of maternal sensitization. Level of 1:8 rarely results in fetal jeopardy. If titer reaches 1:16, amniocentesis is performed to determine optical density (change in OD) of amniotic fluid to estimate fetal hemolytic process. Rising bilirubin levels can indicate the need for an intrauterine transfusion. Genetic testing allows early ID of paternal zygosity at the RhD gene locus, thus allowing earlier detection of the potential for isoimmuinization and precluding further maternal or fetal testing.

The indirect Coomb’s test is repeated at 28 weeks. if result remains negative, indicating that sensitization has not occurred, the woman is given an IM injection of Rh0(D) immune globulin. If test result is positive, showing that sensitization has occurred, it is repeated every 4-6 weeks to monitor maternal antibody titer.

Prevention of hyperbilirubinemia is the primary prenatal focus of care. implementation of interventions focused on the care of woman whose fetus is at risk for essential to prevent problems in newborn. Prenatal control of diabetes mellitus, prevention of maternal infection, avoidance of drugs such as diazepam and salicylates near time of birth and prevention of preterm birth reduces risk.

Fetus and maternal antibody titers are monitored prenatally. Several methods used to detect fetal anemia: amniocentesis to measure chg, PUBS or cordocentesis, and middle cerebral artery peak systolic velocity (MCA-PSV).

Although ultrasound-guided cordocentesis is the gold standard for detecting fetal anemia, MCA-PSV is being used increasingly as an accurate, noninvasive means to detect fetal anemia. This is done using Doppler ultrasound.

If amniocentesis reveals that the chg OD is high or the MCA-PSV is increased, cordocentesis is performed to asses fetal hematocrit. If hematocrit is less than 30%, intrauterine transfusion is indicated. Intrauterine transfusion can e done every 1-2 weeks between 26-32 weeks. if endangered fetus is at more than 32 weeks, a preterm birth may be indicated, usually be cesarean.

Postpartum interventions focus on preventing sensitization in mom, if it has not occurred already, and treating any complications in neonate resulting from hemolysis of RBCs. The unsensitized Rh-negative mom whose baby is Rh positive should receive Rh0(d) immune globulin w/in 72 hrs of birth to prevent her form producing antibodies to fetal blood cells that entered her bloodstream during birth. One dose accommodates ~15 ml of fetal RBCs.

At birth the neonate’s cord blood is sent to lab to determine infant’s blood type and Rh status. A Coomb’s test is performed on this cord blood to determine whether there are maternal antibodies in the fetal blood. The antibody titer indicates the degree of maternal sensitization. If titer is high, exchange transfusion may be indicated. In addition, prevention of or prompt therapy for perinatal asphyxia, acidosis, cold stress, sepsis and hypoglycemia will decrease the newborn’s risk for severe hemolytic disease and the susceptibility to kernicterus. Early feeding is initiated to stimulate stooling and thus facilitate the removal of bilirubin.

Exchange transfusion is needed infrequently bc of the improved recognition of neonates at risk of hemolytic disease that can result from isoimmunication. Other factors must always be considered as well, particularly the clinical condition of the infant because it is a procedure w potential complications. Guidelines for initiation of exchange transfusion in relation to serum bilirubin levels in infants of >35 weeks in AAP Subcommittee on Hyperbilirubinemia.

Exchange transfusion is accomplished by alternately removing a small amt of the infant’s blood and replacing it w an equal amount of donor blood. Exchange transfusion replaces the RBCs that would otherwise be hemolyzed by circulating maternal antibodies, removes the antibodies responsible for hemolysis, and corrects the anemia caused by hemolysis of the infant’s sensitized RBCs. It also reduces the serum bilirubin level in infants who have severe hyperbilirubinemia from any cause. If infant has Rh incompatibility, type O Rh-negative blood is used for transfusion so the maternal antibodies still present in infant do not hemolyze the transfused blood. Depending on infant’s size, maturity, and condition, amounts of 5-20 ml of infant’s blood are removed at one time and replaced w donor blood. Double volume or 2 volume exchange replaces approx. 170 ml/kg of body weight, or 86% of infant’s total blood volume. Procedure ~1 hr. after procedure, phototherapy is continued and bilirubin levels monitored every 4 hrs.

Infant is monitored closely during and after procedure, including assessment of HR and rhythm, respirations, BP, temp and perfusion. Preservatives in donor blood lower infant’s serum calcium and magnesium levels. Not uncommon for calcium gluconate to be given during exchange transfusion if symptoms of hypocalcemia become evident. Symptom s include jitteriness, irritability, convulsions, tachycardia, and electrocardiogram changes. Nurse monitors neonate for hypoglycemia during the several hrs after the exchange because the high glucose content of the preservatives can stimulate insulin secretion. These high risk neonates typically have dextrose support through an IV route.

Planning for rehab measures is necessary if kernicterus occurs. Family will need services of many community resources to care for affected child. Interdisciplinary approach that includes social services must be taken.

 

Indications for Amt of Rh Immune Globulin to be Administered

50 mcg: after CVS, ectopic pregnancy, miscarriage, or abortion before 13 weeks

300 mcg: after miscarriage or induced abortion after 13 weeks; PUBS, amniocentesis, placental abruption or placenta previa, trauma, 28 wks gestation, w/in 72 hrs after birth of preterm or term Rh-positive infant

More than 300 mcg: after large transplacental hemorrhage, after mismatched blood transfusion, after 3rd trimester fetal demise

 

Medication Guide Rh Immune Globulin, RhoGAM, Gamulin Rh, HypRho-D, Rhophylac

Action – suppression of immune response in nonsensitized women w Rh-neg blood who receive Rh-positive blood cells because of fetomaternal hemorrhage, transfusion or accident

Indications – routine antepartum preventions at 28 weeks gestation in women w Rh-neg blood; suppress antibody formation after birth, miscarriage, pregnancy termination, abdominal trauma, ectopic pregnancy, amniocentesis, version, or CVS

Dosage and Route – standard: 1 vial (300 mcg) IM in deltoid or gluteal muscle. Microsdose: 1 vial (50 mcg) IM in deltoid muscle, Rh0D immune globulin (Rhyophylac) can be given IM or IV (available in prefilled syringes)

Adverse Effects – myalgia, lethargy, localized tenderness and stiffness at injection site, mild and transient fever, malaise, headache; rarely nausea, vomiting, hypotension, tachycardia, possible allergic response

Nursing Considerations:

  • Give standard dose to mom at 28 wks as prophylaxis or after an incident or exposure risk that occurs after 28 weeks (amniocentesis, 2nd trimester miscarriage or abortion, and after version)
  • Give standard dose w/in 72 hrs after birth if neonate is Rh+
  • Give microdose for 1st trimester miscarriage or abortion, ectopic pregnancy, CVS
  • Verify that woman is Rh negative and has not been sensitized, if postpartum that Coomb’s test is negative, and that baby is Rh positive. Provide explanation about procedure, including purpose, possible side effects, and effect on future pregnancies. Have woman sign consent form if required by agency. Verify correct dosage and confirm lot # and woman’s ID before giving injection; document administration. Observe client for at least 20 min for allergic response
  • Document lot # and expiration date in client record
  • Medication made from human plasma (consideration if woman is Jehovah’s Witness). Risk of transmitting infectious agents, including viruses, cannot be eliminated completely.

Rh immune globulin suppress immune response. Woman who receives both Rh immune globulin and live virus immunization such as rubella must be tested in 3 months to see if she has developed rubella immunity. If not, will need another dose of vaccine.

 

RH (Rhesus) or RHD Blood Incompatibility – presence or absence of antigen called RH or RhD factor. If blood type includes a plus sign, Rh is present. More than 85% of population is Rh positive. If includes a minus sign, Rh factor is absent. 15% of Caucasians, f3-5% of people of African descent and few people of Asian descent are Rh negative.

If blood is Rh negative, baby’s father needs to have blood tested as well. Although you and baby don’t share blood systems, if you and baby are Rh incompatible, his blood may enter your bloodstream when you give birth or if you experience a miscarriage or have invasive tests such as amniocentesis or chorionic villus sampling (CVS). You may start producing antibodies that may cause mild to severe anemia in your baby. body produces antibodies slowly, so first pregnancy might not be affected.

Injecting an Rh-negative mom with Rh immune globulin (Rhogam) at 28th week can prevent Rh sensitization. Also given after a miscarriage or abortion, with any invasive procedure or if necessary after uterine bleeding or trauma. If blood test finds baby Rh positive, mom will receive another dose within 72 hours of birth.

If you are Rh negative your caregiver will test blood for antibodies throughout pregnancy. If level of antibodies increase, amniocentesis helps assess how seriously the antibodies have affected your baby. in severe cases of anemia in baby, treatment may include early birth and a blood transfusion to replace blood cells. Only in extreme cases does a baby need a blood transfusion in the womb.

  1. Placenta previa and placental abruption

Complications with Placenta – a few women develop problems with how and where placenta attaches to uterus. 2 most common:

  • Placenta Previa – less than 1% of pregnancies; placenta lies completely or partially over cervix. Cant deliver baby vaginally; planned cesarean, after 36th week before labor begins. In early pregnancy, may learn placenta is attached to lower part of uterus (low-lying placenta); in most cases, as uterus grows, site where placenta attached rises away from cervix (if don’t have low-lying placenta in early pregnancy, you won’t develop placenta previa later). Caregiver will diagnose you with placenta previa only if transvaginal ultrasound scan confirms that placenta continues to cover cervix later in pregnancy. Risk factors: prior cesarean, uterine surgery or abortion; uterine abnormalities; >34 yrs old; many previous pregnancies and heavy smoking. Most common symptoms is painless vaginal bleeding as cervical changes occur in last trimester. Treatment depends on symptoms and includes measures to prevent heavy bleeding and decrease risk of preterm birth. If haven’t had bleeding, caregiver will avoid doing vaginal exams and will advise you to avoid sex and heavy exertion. May be put on bed rest. If had vaginal bleeding, may be hospitalized for close observation and if blood tests show severe blood loss, have a blood transfusion.
  • Placental Abruption – 1 % of pregnancies; placenta partially or almost completely separates from uterine wall during 3rd trimester or during labor. Can cause significant blood loss in mother and can deprive baby of adequate oxygen. Risk increases if have 1 of following factors: extremely high blood pressure, more than 5 previous pregnancies; history of 2nd trimester bleeding; prior abruption; habit of heavy smoking or cocaine use; severe abdominal trauma. Abruption may cause any or all of the following symptoms: vaginal bleeding, continuous severe abdominal pain, lower back pain, tender abdomen and constant tightening of the uterus. Sometimes, vaginal bleeding is absent if blood collects high in the uterus. Ultrasound scan may help determine degree of separation and its effect on blood flow to placenta. Assessing mother’s blood pressure and baby’s heart rate helps estimate severity of abruption and along with testes to check how well mother’s blood clots, help determine appropriate treatment. When abruption is small and baby remains healthy, bed rest and close observation may be the only treatment. If bleeding is severe and baby’s heart rate shows distress (and if baby’s chances of surviving preterm birth are high), woman has an immediate cesarean birth and blood transfusion if necessary.

 

  1. Gestational hypertension, preeclampsia, and eclampsia

Gestational Hypertension and Preeclampsia – Expect caregiver to monitor your BP and baby’s well being closely throughout pregnancy. If condition is mild and stable and remains that way, pregnancy is allowed to continue to term. Be aware that preeclampsia rarely improves and often worsens as pregnancy continues. In severe cases, or when blood tests indicate HELLP syndrome, most caregivers recommend managing a woman’s labor in order to keep her BP down and prevent seizures from eclampsia.

Caregivers recommend inducing women because ending pregnancy is often 1st step to resolve problem. Some also recommend epidural because of its suspected side effect of lowering BP; however studies haven’t shown this practice to be effective.

 

High Blood Pressure and Gestational Hypertension – your activity level, emotional state and body position can affect blood pressure. Lower when at rest, lying down, or free of emotional stress. Higher when active, upright or stressed. Short term changes are normal; however pressure that stays too high can cause health risks at any age.

Someone with high blood pressure (hypertension) has had at least 2 consecutive readings over 140/90. Affects 10% of pregnancy women in U.S.; can be chronic or develop during pregnancy. When it first appears after 20th week of pregnancy and remains high for several readings, it’s called gestational hypertension or pregnancy-induced hypertension (PIH).

Pregnant woman with high blood pressure is at risk for serious problems with uterine and placental blood flow and possible damage to other internal organs. Reduced blood flow to placenta can result in less oxygen and fewer nutrients for baby and may cause growth problems. Gestational hypertension can also develop into a more dangerous condition called preeclampsia.

Preeclampsia – previously called “toxemia” is a multi organ condition with mild to severe symptoms that affects ~5-8% of pregnancies. Typically occurs after 20th week of pregnancy and first signs are gestational hypertension and proteinuria (protein in urine). Mild preeclampsia developed near term may cause fewer health problems than severe preeclampsia, which begins before 30th week of pregnancy. With early diagnosis and aggressive treatment, complications are generally minimal and mom and baby are typically healthy at birth and afterward.

Risk Factors for Preeclampsia – Causes aren’t well understood; combination of factors appears to trigger the condition. Some women are higher risk. Most significant risk factors:

  • First pregnancy
  • Preeclampsia in previous pregnancy (or close family member with it)
  • Personal history of chronic hypertension, diabetes, kidney disease, polycystic ovarian syndrome (PCOS), or vascular disease
  • Obesity
  • Age older than 35 or younger than 18
  • Pregnant with multiples
  • African descent
  • History of certain autoimmune disorders, such as lupus or rheumatoid arthritis
  • Infections during this pregnancy, such as periodontal disease or UTI

Complete risk assessment may include a combination of tests, such as blood and urine tests and uterine blood flow studies.

Other signs of preeclampsia – 2 screening tests can detect early signs of preeclampsia. Urine test will show proteinuria and routine blood pressure checks will discover high blood pressure. If have any of following signs, call caregiver immediately:

  • Sudden puffiness (edema) in hands/face
  • Rapid weight gain (more than 2 pounds in 1 week)
  • Headache
  • Visual changes or problems (Flashes or spots before eyes or blurred vision)
  • Pain in stomach (epigastric pain) or right side under ribs, or possible pain in shoulder or lower back

It’s possible – but rare – that woman with preeclampsia will have high blood pressure and proteinuria and have none of they other symptoms. Particular sign usually indicates the specific organ system affected. The more systems affected, the more severe the condition. Severe preeclampsia can cause: placenta abruption; HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) which indicate blood and liver complications; eclampsia, which indicates neurological irritability and imminent convulsions; seizures, stroke, coma or even death of mother and baby (in most severe cases)

Treating Preeclampsia – Only cure is birth of baby (normal blood pressure usually returns within days or weeks). Treatment to avoid further complications is available based on severity of disease and baby’s gestational age and health.

If symptoms are mild (bp over 140/90, proteinuria, fluid retention), treatment usually includes decreased activity or bed rest, blood pressure checks and close observation. May receive medications to lower blood pressure or to reduce risk hypertension will slow baby’s growth.

If have severe preeclampsia (bp over 160/110, proteinuria accompanied by liver, blood or neurological complications), you’ll be hospitalized and given drugs such as antihypertensive and magnesium sulfate to reduce risk of seizures. PCNguide has more info. Continue to receive magnesium sulfate for at least 24 hours after birth to prevent seizures.

If severe symptoms worsen or don’t sufficiently improve with treatment, caregiver may suggest inducing labor or performing planned cesarean. If concerned how a preterm birth will affect baby, may want to postpone induction. If health of baby’s life isn’t in jeopardy, caregiver may suggest delaying birth for a day or 2 so you can receive corticosteroids to promote baby’s lung development before birth.

Reducing Risk of Developing Preeclampsia – for women at risk, taking a low dose aspirin (50-150 milligrams) each day helps reduce risk and may decrease rate of perinatal death and increase babies birth weight. Studies on folic acid supplementation in 2nd trimester show reduced risk. Early detection helps decrease risk of developing severe preeclampsia and other complications. Attend all prenatal appointments, have appropriate screening tests and work with caregiver to control high blood pressure and treat early signs. If contract any infection, consult caregiver for early treatment. Infection may increase risk.

  1. Preterm labor & fetal maturity

Signs of Preterm Labor – some women without any risk factors deliver babies early; only 12% of women have. If have 2 or more symptoms, call caregiver

  • Uterine contractions that occur every 10 min or 6 contractions in 1 hr
  • Continuous or intermittent menstrual-like cramps or pressure in lower abdomen and thighs (pelvic heaviness)
  • Dull ache in lower back that doesn’t go away when change position
  • Intestinal cramping with or without diarrhea or loose stools
  • Sudden increase or change in vaginal discharge (watery, blood tinged, or with more thin mucus)
  • General feeling that something isn’t right

Having persistent, fairly regular contractions for 2 hours (along with other signs) indicates labor

Predicting Preterm Labor – results of several tests can increase likelihood:

  • Fetal fibronectin (fFN) is a protein that increases in last weeks of pregnancy and during labor. When test detects it between 22nd and 35th weeks, risk preterm labor increased
  • Transvaginal ultrasound scan or vaginal exam can determine cervical length. If woman’s cervix shortens months or weeks before term with labor contractions
  • Blood tests for specific biochemical markers and saliva test that looks for increase of hormone estriol

Diagnosing Preterm Labor – if ultrasound or vaginal exam detects shortening and opening of cervix. Women pregnant with multiples – babies expand uterus to size that may naturally cause these changes so caregivers will use additional tests

 

Labor Complications and Interventions – compared to normal labor, complicated labor is longer, more painful or more difficult and may require medical help to ensure well0being of mom and baby.

Most labor complications rarely pose immediate problems that require prompt medical attention.   If potential problem arises, such as slow cervical dilation, it may be resolved simply with time, patience and self help techniques. Problem becomes complication only if these approaches don’t resolve it. Caregivers may use interventions such as induction, episiotomy, continuous EFM, cesarean and others. For every complication, there are usually several possible interventions. Caregivers consider many factors such as: circumstances of woman’s pregnancy and labor, woman’s preference, current scientific evidence, hospital policies, legal liability issues, caregiver’s training, professional peer pressure, cost of interventions.

Some occur more than others. From most common got least common:

  • Need/wish to start labor
  • Prolonged active labor
  • Concerns about baby’s well being
  • Pronged 2nd stage of labor
  • Preterm labor and premature birth
  • Gestational hypertension
  • Multiples
  • Breech and other difficult presentations
  • Complications in 3rd stage
  • Rapid unattended birth
  • Prolapsed cord
  • Seriously ill newborn or infant death
  • PCN 286 Medical Approaches to Relieve Back Pain
  • Sterile water block – if have severe back pain but want to minimize use of pain medications, this is a promising option. Caregiver injects tiny amounts of sterile water into 4 places on lower back. Provides almost immediate pain relief by rapidly increasing endorphin production in area around injection sites. Effects last hour or two. First injections may feel like bee stings for up to 30 sec but additional are less noticeable. Doesn’t relieve abdominal pain
  • Medications for pain relief – if have severe pain during prolonged active labor, can ask for epidural or spinal narcotics.

 

Preterm Labor and Premature Birth – labor is preterm if begins before 37th week. The younger a premature baby’s gestational age, the more problems likely she’ll have.

Certain indicators can identify women at high risk: previous miscarriage, prior premature birth, cervix that’s short, ripe or dilating early in pregnancy. Caregivers may recommend bed rest, medications and cervical cerclage to stop preterm labor and prevent a premature birth.

Some women have no risk factors. If you see any signs, call caregiver immediately. Methods used to prevent more likely to succeed if it’s detached before cervix has dilated to 2 cm. Because it’s a high risk situation, usually involved OB. If premature birth unavoidable, pediatrician or neonatology is typically present for immediate evaluation and treatment of baby.

What to Expect if You Have Preterm Labor:

  • May be asked to drink 1-2 large glasses of water and lie down for an hour, then call again if contractions contraction. Mild dehydration sometimes causes contractions
  • If go to hospital, contractions are evaluated with EFM and may receive vagina exam or ultrasound to discover whether cervix is changing. If it isn’t changing, you aren’t in preterm labor. May have an active or irritable uterus and may be told to rest
  • If cervix is changing, caregiver checks whether baby’s lungs are mature enough so he can breathe on his own after birth. Withdraws small amount of amniotic fluid from uterus (amniocentesis) and analyzes surfactant levels
  • If baby is immature and birth seems unavoidable, focus of care shifts to prevention of respiratory distress syndrome (RDS)- the most common complication of premature birth. Caregiver may tri to delay birth for a day or 2 in order to allow time for corticosteroids to speed up maturing of baby’s lungs. This reduces incidence of RDS by 40-60%; they may also help decrease intracranial bleeding (Brain hemorrhage) in newborn
  • Drugs used to stop/slow preterm labor are powerful and have strong side effects. Highest doses used only for a day or two then lower doses combined with bed rest for longer period to keep preterm contractions from increasing in frequency and intensity
    • Beta mimetic agents (terbutaline and ritodrine)
    • Calcium channel blockers (nifedipine)
    • Prostaglandin inhibitors (naproxen and indomethacin)
    • Oxytocin receptor antagonists (atosiban)
    • Magnesium sulfate (used to treat gestational hypertension has also been used to stop preterm labor but has proved unsuccessful and produces uncomfortable side effects and is dangerous to baby
  • Giving mom systemic pain mediations (narcotics) isn’t recommended since can affect baby’s heart rate and sometimes breathing after birth. Plan to use relaxation and breathing patterns for pain relief in early labor and can request regional anesthesia (epidural) in active labor, which has less effect on newborn

Care of the Premature Baby:

  • If baby is born before corticosteroids have had enough time to mature her lungs, treatment for RDS becomes necessary, which includes administering oxygen and mechanical assistance with breathing. Baby may need to have surfactant instilled into her lungs, which allows lungs to expand during an inhalation and remain partially inflated during an exhalation
  • If baby is very premature, may need to transfer to hospital with intensive care nursery. Because baby is at high-risk, heart rate may require continuous monitoring
  • Might not be allowed to hold baby right away. Most premature infants taken to special care nursery or NICU, where they stay until they can breathe on their own, stay warm at room temperature and breastfeed or take a bottle
  • Baby may require prolonged hospitalization. Participating in baby’s care benefits both child and adults.

Kangaroo Care – newborns kept skin to skin with one of parents as much as possible. Proponents believe it’s the most effective way to promote a baby’s well-being, especially for premature or sick baby. as soon as newborn’s condition is stable, he’s placed nude on mother’s bare chest or abdomen. Blanket covers both of them. Several times a day.

Studies show baby’s growth and development improve with Kangaroo care. Baby spends more time in deep sleep, more time in quiet-alert state and less time crying. He has fewer episodes of apnea (suspension of breathing) and fewer episodes of bradycardia (slow heart rate). His temperature stabilizes, and he gains weight more rapidly which can lead to shorter hospital stay if he’s ill or was born prematurely. Premature baby’s health particularly improves when allowed to smell his parents’ familiar scent, hear their heartbeats, and absorb their body heat. Skin to skin helps easy any anxiety he may have from being connected to various monitors, IV lines, and tubes for oxygen and food. If at risk, contact newborn nursery to learn more about policies and how to arrange.

 

Breech and Other Difficult Presentations – typically at birth, baby positions herself so her head is over the cervix; this vertex presentation is most favorable for vaginal birth. In 5% of births, baby is in less than favorable presentation. Face and brow occur in less than half of 1% of births; they usually prolong labor. Very rare shoulder presentation (transverse lie) 1/500 birth; cesarean usually necessary.

  • Breech presentation occurs in 3-4% of births, although incidence rises with multiples or premature births. 3 types:
  • Frank: baby’s buttocks are over cervix and legs are straight up toward her face (most common breech)
  • Complete – sitting cross legged over cervix
  • Footling: one or both of baby’s feet are over cervix

In U.S. breech babies are typically born by cesarean. Many women try to turn breech babies before birth by using self-help techniques.

 

III. Labor Complications and Interventions

  1. First Stage
  2. Common medical interventions
  3. a) Continuous blood pressure monitoring

Blood Pressure – arterial BP (brachial artery) varies w age, activity level, presence of health problems, circadian rhythm, use of alcohol, smoking and pain. Additional factors to consider during pregnancy include maternal position and type of BP apparatus. Maternal anxiety can elevate readings. If an elevated reading is found, the women is given time to rest and the reading repeated.

Maternal position affects readings. Brachial BP highest when woman is sitting; lowest when lying in lateral recumbent position and intermediate when she is supine, except for some women who experience hypotensive syndrome. Therefore, at each prenatal visit, the reading should be obtained in same arm w woman in seated position w back and arm supported and upper arm at level of right atrium. The position and arm used should be recorded along w reading.

Proper size cuff essential for accurate readings. Cuff too small yields a falsely high reading; cuff too large yields falsely low reading.

Caution should be used when comparing auscultatory and oscillatory BP readings because discrepancies can occur. Automate monitors can give inaccurate readings in women w hypertensive conditions.

During pregnancy maternal BP remains same or decreases slightly. This is due to reduced systemic vascular resistance caused primarily vy the vasodilatory effects of progesterone, prostaglandins, and relaxin. The uteroplacental vascular system holds a large % of maternal blood volume, which also contributes to decreased systemic vascular resistance. Systemic vascular resistance is lowest at 16-34 weeks and increases gradually, approximating nonpregnant values by term. During 1st trimester, systolic PB usually remains the same as prepregnancy level but can decrease slightly as pregnancy advances. Diastolic BP begins to decrease in 1st trimester, continues to drop until 24-32 wks, and gradually increases, returning to prepregnancy levels by term.

Calculating the mean arterial pressure (MAP) (mean of the BP in the arterial circulation) can increase the diagnostic value of the findings. MAP is useful in predicting gestational hypertensive disorders in the 2nd and 3rd trimesters. Normal MAP readings in the nonpregnant woman are 86 +- 7.5 mm Hg. MAP readings during pregnancy range from 84-85 +/- 7.

Some degree of compression of the vena cava occurs in any woman who lies on her back during the 2nd half of pregnancy. Cardiac output is reduced by as much as 25-30% when a pregnant woman is turned from left lateral recumbent to supine position. Some women experience a fall of more than 30 mm Hg in their systolic pressure. After 4-5 min, a reflex bradycardia is noted, cardiac output is reduced by half and woman feels faint.

Procedure for BP Measurement

  • Use correct cuff size; cuff should cover ~880% of upper arm or be 1.5x length of upper arm
  • Measure BP after the woman sits for 5 min
  • Instruct the woman to refrain from tobacco or caffeine use 30 min before BP measurement
  • Measure BP w woman sitting or semi-reclining w feet flat, not dangling
  • The arm should be supported on a desk at the level of the heart
  • Measurements with an automated device should be checked w a manual device
  • Diastolic pressure should be recorded at Korotkoff phase V (disappearance of sound)
  • If BP is elevated, have woman rest for 5-10 min and retake
  • BP may vary by more than 10 mm Hg form one arm to the other; record higher reading
  • Take average of 2 readings at least 1 min apart

 

Calculation of Mean Arterial Pressure

BP: 106/70

Formula: Systolic + 2 (Diastolic) / 3 = 106 + 2(70) /3 = 106 + 140/3 = 246/3 = 82 mm Hg

 

Routine Exams and Screening Tests:

Every visit

  • Urine test to detect bacteria, protein and sugar (at first visit, urine test can confirm pregnancy)
  • Blood pressure check to screen for high blood pressure
  • Weight check to monitor nutritional status and detect sudden weight gain (which can indicate preeclampsia)
  • Abdominal exam – to measure uterine growth or fundal height (which indicates baby’s growth) and estimate baby’s position
  • Fetal heart tones – listen to confirm baby’s well being

Specific Visits

  • Pelvic exam – confirm pregnancy, estimate size of mother’s pelvis, check for infection or perform Pap smear. In late pregnancy, reveals cervical changes
  • Blood test – at first visit to confirm pregnancy, determine blood type, test for anemia, and assess exposure to infection. For women with diabetes, caregivers check blood glucose levels periodically throughout pregnancy
  • Breast exam – screen for breast cancer and assess for conditions affecting breastfeeding

See PCN Guide

  1. b) Intravenous access and fluids
  • Arriving at Hospital/Birth Center: Report info in Early Labor Record (pg 175), make sure have bag, birth plan and any last min items (towel if you bags of water are leaking). Do not drive yourself, have partner drive. Ride to birthplace may be challenging and uncomfortable. Focus your breathing on something in vehicle to give you a rhythm to follow. Go to triage. If think bags of water has broken, nurse may give you sterile speculum exam to obtain a sample of amniotic fluid for diagnosis. If they decide you are in early labor, you may be asked to leave until labor pattern changes. Should follow this advice to keep busy at home. Labor is likely to progress min environment that feels safe, secure and familiar. If don’t want to return home, take a walk nearby or go to cafeteria. When admitted, will take medical history, get urine/blood samples, check baby’s heart rate and progress. Change into hospital gown or bring your own and get an ID bracelet. May have IV catheter inserted at this time. Nurse begins monitoring contractions and baby’s heart rate for 20-30 min, typically with external electronic fetal monitor or possible with hand-held Doppler.

IV Fluids in Normal Labor – in some hospitals, its routine to insert IV catheter in all laboring women shortly after they’re admitted. They carry a few mild risks. See PCNGuide. It can limit mobility in labor because you’re connected to a wheeled pole that holds bag of fluids. Ask if it’s routine at prenatal appointment. If routine, ask whether can have a Hep Lock (Heparin Lock) which involves inserting an IV catheter, but doesn’t require hooking it to an IV bag until IV fluids are needed.

 

Effects of IV Hydration on Maternal Stress, Breast Edema and Lactogenesis: increased use of epidural accompanied by increased use of IV hydration to prevent supine hypotension. Breast, nipple and areolar edema on 2nd or 3rd postpartum day that seem to be correlated with IV fluid hydration. Edema inhibits or prevents deep attachment at the breast. Preventing milk stasis by ensuring early and effective milk drainage is the most critical strategy for ensuring normal lactogensis. Not enough milk is the most reported reason that babies are given supplemental feeds and mothers stop breastfeeding. Milk stasis longer than 6 hours after birth interferes with normal establishment of full lactation. Postpartum breast engorgement is a major barrier to establishment of effective and comfortable breastfeeding. Oxytocin and oxytocin augmentation and induction in labor can cause fluid retention in mother. Reverse pressure softening to overcome severe breast edema. Moms leave hospital 2-4 days after birth with no lactation support.

Effects of IV Hydration on Infant Status, Ability to Feed and Risk of Supplementation: excess fluids in laboring women related to infant hypoglycemia, hyponatremia, electrolyte imbalances and hyperbilirubinemia. Develop jaundice more often. Any respiratory compromise affects baby’s ability to feed. Jaundiced babies feed poorly and are more likely to be supplemented. Babies whose mothers had glucose IVs were 3x more likely to by hypoglycemic, causing lower muscle tone and delayed habituation to various stimuli at 2 hours of age. No change in suck and root reflex, but muscle tone related to infant sucking and feeding ability. Hypoglycemics often separated from mom for testing. Appropriate therapy is IV glucose, not oral fluids. Excessive weight loss in early neonatal period often a reason for aggressive supplementation.

Other Effects of IV Hydration and Caloric Restriction in Labor: instrumental deliveries higher in moms who had restricted food.

Global Aspects of Hydration in Labor: withholding food and liquid in warm climates. Offering fluid noted fasted labor and better newborn Apgar scores. If acetone (ketones) is present in woman’s urine, suspect poor nutrition and give dextrose IV.

2008, 59% of mothers had IV hydration.

Summary: outdated process that doesn’t improve birth outcomes; can lead to electrolyte imbalances, jaundice and other problems in newborn requiring separation and impacting breastfeeding; can cause edema, perceived by mothers as painful, stressful and restrictive of movement which can lead to prolonged labor and other interventions that impact early breastfeeding.

  1. c) External fetal monitoring

 

Working with Your Labor – after labor nurse finishes assessing you make yourself as comfortable as possible. Continue/begin spontaneous ritual. Use comfort measures as appropriate, such as placing pressure and cold packs on back or hot compresses on lower abdomen and groin. Empty bladder every hour or so; a full bladder increases discomfort and can slow labor. Make sure to keep self-hydrated by sipping water after a few contractions or by sucking popsicle/ice chips.

Try not to lie in bed throughout labor – may increase pain and slow labor progress. Unless need to rest on contractions are coming so fast you can’t move, try to periodically move about in bed or take advantage of gravity by standing and walking in you room and in the hall.

Continue slow breathing for as long as it helps you relax. Switch to light breathing or one of adaptations if breathing begins to feel labored or If can’t keep breathing rate slow, or if can’t maintain your rhythm. Light breathing may be better suited for demanding contractions than slow breathing, just as short, quick breaths are better suited for demanding physical exercise than long, deep breaths are. By tuning into contractions, you can adapt your breathing rhythm as needed.

Monitoring You and Baby during Normal Labor – as long as labor is normal and baby is doing well, you don’t need medical procedures. PCNGuide has description of techniques if monitoring indicates a complication has developed in labor

  • Monitoring You – regularly checks blood pressure, temp, pulse, urine output, fluid intake, activity and emotional state. Vaginal exams periodically to determine effacement and dilation of cervix and station, presentation and position of baby. recorded on chart which shows labor progress. Observes frequency and intensity of contractions by hand or electronic monitor.
  • Monitoring baby with fetal heart rate monitoring – many things influence baby’s heart rate during labor: your contractions, baby’s activity (fetal movements), medications, body temp, position and other factors. Normal range is 120-160 bpm. Varies in response to changes in amount of oxygen that’s available. If baby is handling labor well, he has a reactive heart rate, which naturally slows down to compensate for temporary reductions in oxygen during a contraction and speeds up between contractions. Indicates he’s compensating well to normal variations in oxygen flow.
    • Depending on maturity/health of baby, ability to compensate varies. If lack of oxygen continues over time, his reserves may become exhausted. May not be able to compensate and might become distressed (also known as nonreassuring fetal heart rate or fetal intolerance of labor). Close observation and further testing help identify those who aren’t tolerating well and may need immediate medical intervention
    • Baby’s heart rate can be monitored by auscultation or by electronic fetal monitoring (EFM). Auscultation – listens during and between contractions with a Doppler, or hand held ultrasound stethoscope. May place a hand on abdomen to feel contractions, then count heartbeats, nothing whether speed up or slow down.
    • Two types of EFM – commonly used external EFM uses belts to place 2 sensor son abdomen and rarely used internal EFM uses 2 sensors placed inside uterus (only used if external isn’t picking up signals). 1 sensor picks up baby’s heartbeat, other picks up changes in uterine tone or pressure. Sensors connected to video screens in room or at nurses station. 2 graphs showing baby’s heart rate and intensity of contractions. All date stored electronically

 

Electronic Fetal Monitoring: instrumental delivery and cesarean surgery rates higher in EFM groups and when there was not the added technology of fetal scalp pH sampling to assess true fetal distress, the cesarean surgery rates were “much” greater.

  • Woman undergoing EFM is confined to bed (unless capability for walking telemetry, which is very expensive and uncommon)
  • EFM conveys a clear message to a woman in labor, through the belts and leads and machinery, that she and her unborn baby are labor patients who must be monitored with noisy and often intimidating technology. Moving to and from toilet or changing position in bed becomes a problem, requiring the assistance of a nurse
  • If there is internal monitoring, the fetal scalp must be lanced to allow the application of the monitor lead, which causes pain to the fetus; opens a wound, which increases risk of infection; and may impact the newborn’s comfort and ability to breastfeed
  • There is a well-documented association between apparently false interpretations of fetal distress and EFM, which if not confirmed with additional fetal blood sampling lead to a rush for instrumental or cesarean delivery. These interventions bring another cascade of interventions that impact breastfeeding.
  1. d) Internal fetal monitoring

 

  1. e) Induction

Interventions Can Cascade – as they attempt to initiate breastfeeding. Inductions for noncompelling reasons triggers harder, closer contractions and usually a less-mature baby. lack of continuous support in labor, esp among young 1st time moms, can create poor coping behavior, exacerbate anxiety and pain and slow labor progress. Slowed labor may necessitate augmentation with IV oxytocin to bring stronger, more regular contractions and may require woman to be confined to bed with decrease in ability to walk or even to change positions. In most settings, oxytocin drip protocols often require continuous EFM, thus further limiting woman’s movements. With strengthened contractions, mother may become more anxious and pain may increase, leading to a need for pain medications. Narcotic analgesia can lead to slowed and/or dysfunctional labor and thus, ironically, the oxytocin dose must be increased to further strengthen labor. Labor medications affects newborns ability to suck, swallow and breathe normally to initiate breastfeeding. Regional/spinal epidural anesthesia for pain relief in labor is linked to higher rates of instrumental and surgical deliveries; some studies associate these interventions with breastfeeding difficulties. Withholding fluids and calorie support to laboring woman “in case” she might need a cesarean contributes to ketoacidosis (Breakdown of mom’s fat stores), which hinders labor progress and stresses baby further.

One intervention usually leads to more. If oxytocin and its related interventions to not move labor along at the prescribed rate (in some settings this is based on the partograph, an international labor guide that mandates a cm dilation per hr), then cesarean may be done. Or, if mother is in 2nd stage of labor, forceps or vacuum extraction devices may be used.

The cascade continues. Long, difficult and/or assisted labors are linked to breastfeeding difficulties in mom and infant. If an assisted or surgical delivery was performed for fetal distress, baby may not be in a condition for early initiation of breastfeeding. If it was an assisted or surgical delivery for obstructed labor (failure to progress), mom may be exhausted, under influence of labor and/or surgical anesthesia, in pain or all 3. Frequently both mom and baby will be separated after birth. Even when both mom and baby are fine, newborn procedures are often performed immediately after delivery, thus interfering with uninterrupted skin-to-skin.

The number of Baby-Friendly steps in place predicts risk of breastfeeding cessation. (Steps measured: early bf initiation; exclusive breastfeeding; rooming-in; on-demand feedings; no pacifiers)

 

Summary of Cascade of Interventions (Physics and Forces) on Breastfeeding Outcomes:

Intervention/ Possible Impact on Breastfeeding

  • Labor anesthetics
    • Maternal breast odor by itself guided newborns toward breast after vaginal births
    • Maternal anesthetic agents also affect motor nerves, resulting in a longer 2nd stage of labor; anesthetic agents also affect infant’s breathing, sucking and muscle tone
    • Labor epidural anesthesia had a negative impact on breastfeeding in the first 24 hrs of life, even though it did not inhibit the % of breastfeeding attempts in 1st hr
  • Induction of labor
    • Done for less than compelling medical reasons may result in a near-term or “borderline” baby
  • Newborn complications
    • Increases risk of separation of mom and baby, which is a well-known barrier to establish breastfeeding
  • Separation of mom and baby
    • Alteration in oral motor functioning may happen when baby is separated from mom and separated babies cry more; crying increases risks of post birth intercranial bleeds; intercranial bleeds symptoms include hypotonia or hypertonia, disturbed swallowing, disturbed sucking, transient apnea, and tremor or jerks
  • Keeping mom and baby together
    • Maternal holding is comforting; breastfeeding is pain-relieving, breastmilk contains natural pain-relievers, and breastfeeding is calming to the central nervous system, which helps baby to self-regulate
  • If interventions contribute to baby not being able to feed effectively:
    • Colostrum and milk remain in the breast, causing or exacerbating engorgement and triggering early mammary involution as early as a few days post birth
    • Breastfeeding itself is fundamentally different from sucking on other objects and has long-term implications
    • For the mother, giving birth to a baby who cannot suck, swallow and/or breathe normally is an enormous, devastating shock
    • Mothers whose babies cannot feed at breast often grieve for months or years afterwards

 

Outcomes of Labor Induction– from ancient times until ~1900, ergot (rye fungus) was used to start labor. Daylight deliveries (elective inductions) became popular in 60s and 70s, coincidentally w lowest breastfeeding rates in recent history. Buccal Pitocin (a tablet place din woman’s cheek) was used at time, and interest increased in nonmedical techniques of nipple stimulation, stripping the membranes, and oral intake of castor oil. FDA disapproved elective inductions in 70s due to iatrogenic prematurity, overcrowded NICUs and huge unnecessary costs. The effect on breastfeeding was not considered.

Babies born after labor is induced are 3x more likely to die or be admitted to intensive care. And challenges establishing breastfeeding.

Inducing labor causes more pressure on presenting part of baby, usually the head. Baby has less time to recover between contractions and is therefore more stressed. More powerful contractions lead to more chemical pain relief from mom and therefore exposing baby to even more drugs. Maternal fever is dose-related to duration of epidural, which is also associated w infant fever and more separation and testing of infant including septic workups.

Amniotic-fluid embolism is a major and potentially fatal complication of labor induction. Although absolute risk is low, women and physicians should be aware or risk when making decision.

Failed induction is another barrier to smooth establishment of breastfeeding. Mother endures hours or even days of artificially strong and painful contractions that do not accomplish vaginal birth, instead culminating with cesarean. Now mother and baby must cope with postsurgical complications including pain, medications and more risk of separation.

Effects on Breastfeeding – immature baby’s suck response is typically weak, disorganized and immature; therefore baby’s ability to obtain milk is compromised. Baby may also have respiratory difficulties, injuries from instruments and/or birth insults from more forceful labor. All drugs need to be metabolized by baby’s immature liver, leading to increased incidence of hyperbilirubinemia and jaundice, even kernicterus.

At the very least, jaundiced babies feed poorly. Conversely, ineffective feeding can cause/exacerbate jaundice. Caloric intake and supplementation become an urgent issue. Once supplementation becomes an issue, avoidance (or use) of breastmilk substitutes and feeding bottles becomes an immediate concern.

Separation of mom/immature baby is very common in many places, even though separation stresses fragile baby, mom and breastfeeding relationship even further. Mother must begin expressing milk by hand or pump within 6 hrs after birth –exactly when she is worried most about condition of her baby and possible struggling with after effects of a medicated and/or surgical birth herself.

Expert skilled help is appropriate when baby cannot feed directly, which means mom/baby must now cope with additional and specialty trained personnel assisting her w normal breastfeeding.

WHO estimates induction of labor medically necessary in ~10% of births. CDC reported 19% induction rate in 2000, while Listening to Mothers survey reported 43% induction rate. 2006 survey II reported 50% of moms attempted to induce, with a 39% success rate.

 

Cumulative Stresses from Induction, Epidural Anesthesia and Surgery

Summary of cascade of interventions includes:

  • Induction of labor triggers cascade of interventions that may include infant immaturity, affecting ability to feed
  • Induction causes stronger contractions than would occur naturally, leading to increased maternal need and desire for chemical pain relief, which affects infant suck
  • Epidural administration requires IV hydration to avoid supine hypotension, which increases breast edema, delays lactogenesis, makes latching difficult, and reduces milk flow
  • Epidural catheters, IV lines and fetal monitors reduce maternal mobility and position changes, resulting in longer labor
  • Longer labor is related to delayed lactogenesis II and increased mechanical stress to infant
  • If epidural wears off or is ineffective, the lack of natural beta-endorphins means mother is likely to experience more pain than if she had not received epidural at all
  • Epidurals slow labor, which may delay onset of lactogenesis
  • Epidural drugs are negatively dose-related to infants ability to suck, swallow and breathe in coordinated manner for breastfeeding
  • Epidural drugs decrease endorphins in colostrum and milk; therefore, the infant affected by longer labor and more risk of instruments and injury receives less comfort from breastfeeding
  • Mothers who experience a physically or emotionally traumatic birth are less likely to begin and continue breastfeeding

 

Baby-Friendly Hospital Initiative even more important for moms/babies who experienced difficult births.

 

  • (1) Common reasons for induction

The Need or Wish to Start Labor

Common Medical Reasons for Induction – if caregiver knows/suspects any of following has occurred, baby and mom will be closely monitored for signs of distress

  • Post-date pregnancy – >42 weeks (many caregivers shorten to 40.5 or 41.5 weeks). After 42 weeks, baby has 5-10% risk of postmaturity, condition in which placenta stops functioning well, baby’s growth slows or stops, and risk of stillbirth gradually increases.
  • Rupture of membranes – after woman’s bag of water breaks, risk of infection increases. If labor doesn’t start on its own within 24 hours (or sooner if tested positive for Group B strep), caregiver may recommend induction
  • Lack of growth in baby – if baby is no longer growing or thriving in uterus
  • Genital herpes – woman is having frequent outbreaks in late pregnancy may induce labor between outbreaks to avoid cesarean
  • Illness in mother – gestational hypertension or diabetes; if illness intensifies over time. Induction recommended if birth will alleviate/cure illness
  • Fear of macrosomia (big baby) – ultrasound scan suggests baby is large for mother’s size and build or is growing rapidly
    • Studies on accuracy of scan estimates show margin of error of at least 10%; often overestimates baby’s size. In cases of shoulder dystocia, only 30% occur in babies that weigh more than 8.5 lbs. Inducing baby because of suspected large baby more often causes labor to stop (arrest of labor), increasing need for cesarean. So don’t recommended on list of medical reasons

Elective Induction (Social)

  • Convenience for caregiver’s schedule – when caregiver is on call
  • Convenience for family’s schedule, support needs or circumstances – for those who can help out after the birth or if woman lives far from hospital or those who need to arrange care of other children during the birth. Or those who had a previous rapid birth and want to better control timing
  • Discomfort in late pregnancy
  • Pregnancy reaches term – 37 weeks, but babies benefit from pregnancies that last closer to 40 weeks. Elective induction shouldn’t be done before 39 weeks to allow babies lungs to fully mature

Reasons to think carefully before consenting to induction – today, elective inductions far outnumber medical inductions in many hospitals. Induce labors outnumber spontaneous labors.

  • Induction leads to a more medicalized birth, with more interventions, such as IV fluids and EFM and fewer options for natural coping and less freedom to move around or use bath/shower.
  • Intervention may make contractions more painful, which may increase need for pain medications
  • It bypasses baby’s ability to start labor at optimal time; babies continue to mature and develop in last weeks of pregnancy. Can cause a premature birth if done too early. It has contributed to rising rate of prematurity in U.S.
  • All methods of inductions carry possible risks, esp uterine hyperstimulation (contractions too strong/frequent) and higher likelihood baby won’t tolerate labor (Ad indicated by EFM)
  • No guarantee that induction will get labor started; if it fails, cesarean is typically performed. Those who had it were 2-4x more likely to have a cesarean.

Medical Conditions that rule out Induction – genital herpes outbreak, placenta previa, previous surgery to remove uterine fibroids, or baby with transverse presentation

Non-Medical Methods for Induction most have had little scientific evaluation but generally simpler and easier than medical induction. Pose milder risks although some have unpleasant side effects. Less likely to start labor than medical methods. PCNguide.

Self-Help Techniques

  • Walking – long walks can help start labor however its more effective at keeping active labor going than it is at starting labor, when extensive walking may just exhaust you
  • Intercourse/Orgasm – orgasm causes release of oxytocin and prostaglandins, 2 hormones that cause uterine contractions and may start labor. Semen also contains prostaglandins. Frequent sex more effective than single act
  • Nipple stimulation – release of oxytocin, lightly stroke or have partner gently caress or suck on them or use pump.   Occasionally, it causes contractions that last too long or are too frequent or painful, so discontinue
  • Castor oil – bowels stimulated to empty. It is a strong laxative thought to increase prostaglandin production. Enemas are also used to stimulate bowel movements, but current studies found them ineffective at starting labor.
  • Acupressure

Complementary Medicine Methods – require supervision of trained professional

  • Herbal tea and tinctures – blue cohosh tea causes uterine contractions but can cause blood pressure to rise to unsafe levels
  • Homeopathic remedies
  • Acupuncture – no known risks. Needles placed at strategic points along meridians, or energy flow lines. Little scientific evidence on effectiveness, but few studies show its beneficial. Moxibustion – burning herbs placed close to acupuncture point

Medical Methods of Induction – choice of method depends on condition of cervix. Induction more likely to succeed if cervix is favorable – ripe, anterior and partially effaced and dilated. Cervix is unfavorable if its firm, posterior and not effaced

Medical Non-drug methods

  • Balloon dilators – have been found to speed up onset of labor by ripening cervix and causing some dilation. Foley balloon catheter (originally designed to empty bladder) or cervical ripening balloon is placed within cervix, where it remains until it falls out when cervix begins to open or until up to 12 hours have passed and its removed.
  • Stripping (or sweeping) membranes – usually quick and relatively noninvasive. Caregiver inserts a finger into cervix to loosen bag of waters from uterine wall in order to prompt the release of hormones that start contractions. May be painful (similar to vigorous vaginal exam) and may cause slight bleeding and cramping, but studies have found it to reduce time until labor begins.
  • Artificial rupture of membranes (AROM) – also called amniotomy; caregiver breaks bag of waters with an amniohook, a long plastic device that resembles a crochet needle. It is rarely successful if cervix is unfavorable, in which case caregiver uses cervical ripening technique prior.
    • Risks and Benefits:
      • AROM for Induction – increases chance of starting labor, especially when used with Pitocin; however, if labor doesn’t start after AROM, chance of cesarean increases. Bacteria can enter uterus after membranes are ruptures, which increases chances of infection to you or baby over time. If need induction for medical reasons, chance of success increases if use it with Pitocin. If want to avoid cesarean, consider trying Pitocin without AROM. If Pitocin doesn’t start labor, it can be discontinued and tried again in a day or 2.
      • AROM to speed up active labor – bag of waters may bulge through cervix during contractions. Performing AROM at this time may cause baby’s head to press more firmly on cervix, likely making contractions suddenly more painful and speeding up labor progress. Without AROM, membranes often remain intact until 2nd stage of labor, and then break spontaneously.
        • If labor is progressing well, might not need AROM. If labor is progressing slowly because baby is an unfavorable position such as OP or her head is tilted back or to the side, may prefer to try other options first to correct baby’s position and speed up labor.
        • Advantage of not rupturing membranes is bag of waters provides baby some cushioning and room for moving into a favorable position. Rupturing membranes may cause baby’s head to stay in an unfavorable position, potentially causing a longer or more painful labor.

Medications to Induce or Augment a Labor – Pitocin aka “Pit” is synthetic version of oxytocin, the hormone your body releases to start labor. (Syntocinon is another synthetic version of hormone). Pitocin is almost always used for medical induction, and it’s sometimes used to help augment a slow labor by increasing the frequency and intensity of contractions. Administered intravenously, allowing dosage to be increased, reduced or stopped, if necessary.

Although Pitocin causes uterus to contract, it doesn’t ripen cervix. If cervix unfavorable for induction, cervical ripening methods are necessary before receiving it.

Medications to Ripen the Cervix– synthetic prostaglandins mimic hormone body releases to ripen cervix. 1 type is prostaglandin E2 or dinoprostone, which comes in a gel (Prepidil) that’s placed next to cervix to speed up ripening. Also available in tampon like device (Cervidil); this may be more desirable choice because medication can be removed entirely if it becomes necessary to stop ripening.

Another type is prostaglandin E1 or misprostol (Cytotec); more likely than the others to cause contractions along with cervical ripening. Comes in a pill that’s taken orally or in a gelatin capsule that’s placed next to the cervix.

2 Options if Induction Leads to Slow Labor Progress (and membranes haven’t ruptured)-

  • Serial Induction – Pitocin discontinued at night to allow you to eat and sleep. May improve chances of vaginal birth. May take several days for labor to start, which can be emotionally and physically draining for you and partner. Done less than in past because family occupying birthing room for days is costly.
  • AROM – membranes are ruptured and dose of Pitocin may be increased quickly. May start labor, but must do so within a certain time frame (12 -24 hrs). if don’t have steady dilation, induction considered a failure and cesarean becomes necessary.

Strange story of Misoprostol (Cytotec)- mid 1990s it was introduced as quick inexpensive way to ripen cervix and induce labor. Use controversial because was approved for stomach ulcers. No research for safe dosages. Using the drug for any purpose other than treatment of stomach ulcers was (and continues to be) “off label”. Helps induce labor quickly, but along with quick labors came severe contractions and distressed babies. Many moms and babies suffered physical harm, and some. Moms found birth traumatic. Research now has recommended low doses (25 micrograms for vaginal use and 50 micrograms for oral use) and dispensed no more frequently than every 4-6 hours. Some believe its as safe as other prostaglandins. After woman’s membranes have ruptured, giving it orally is safer. Women with prior cesarean shouldn’t have it because of increased risk of uterine rupture.

Procedure for Medical Induction

  • Call hospital before leaving home for schedule apptmt. They can’t predict women in labor at one time so fi it’s especially busy, you may be told to call back in a few hours when they have room for you
  • Be prepared to wait. may start in 6-8 hours or may take 3 days or longer. Pitocin most commonly used drug and sometimes takes several hours. Induction that begins with an unripe cervix often takes a very long time to work, or it may fail. If cervix is unripe, induction is postponed so you can have prostaglandins or cervical dilators inserted to ripen cervix. Cervical ripening may require several trips to the hospital
  • Expect continuous EFM, which restricts ability to use self-help comfort measures. Ask if wireless or telemetry monitoring is available
  • Expect to become hungry if they restrict eating while receiving Pitocin. Pitocin increases risk of cesarean section and surgery is safest with empty stomach
  • Be prepared for contractions more intense. Labor is often more painful when induced rather than spontaneous

(2) ACOG accepted reasons for induction

(3) Elective induction

 

(4) Bishop Score

(5) Non-medical induction

 

  1. Walking/movement
  2. Intercourse
  3. Nipple stimulation
  4. Castor oil
  5. Acupressure
  • (6) Medical induction

 

  1. Balloon dilators
  2. Stripping the membranes
  3. Artificial rupture of membranes (AROM)
  4. Medications to induce labor

 

  1. Baby well-being during labor
  2. a) Nonreassuring fetal heart rate patterns

Monitoring baby with fetal heart rate monitoring – many things influence baby’s heart rate during labor: your contractions, baby’s activity (fetal movements), medications, body temp, position and other factors. Normal range is 120-160 bpm. Varies in response to changes in amount of oxygen that’s available. If baby is handling labor well, he has a reactive heart rate, which naturally slows down to compensate for temporary reductions in oxygen during a contraction and speeds up between contractions. Indicates he’s compensating well to normal variations in oxygen flow.

Depending on maturity/health of baby, ability to compensate varies. If lack of oxygen continues over time, his reserves may become exhausted. May not be able to compensate and might become distressed (also known as nonreassuring fetal heart rate or fetal intolerance of labor). Close observation and further testing help identify those who aren’t tolerating well and may need immediate medical intervention

Baby’s heart rate can be monitored by auscultation or by electronic fetal monitoring (EFM). Auscultation – listens during and between contractions with a Doppler, or hand held ultrasound stethoscope. May place a hand on abdomen to feel contractions, then count heartbeats, nothing whether speed up or slow down.

Two types of EFM – commonly used external EFM uses belts to place 2 sensor son abdomen and rarely used internal EFM uses 2 sensors placed inside uterus (only used if external isn’t picking up signals). 1 sensor picks up baby’s heartbeat, other picks up changes in uterine tone or pressure. Sensors connected to video screens in room or at nurses station. 2 graphs showing baby’s heart rate and intensity of contractions. All date stored electronically

Understanding Concern about Baby’s Heart Rate – 2nd most common for cesarean for 1st time moms. Clinical term is nonreassuring fetal heart rate or fetal intolerance of labor or fetal distress.

Monitoring baby’s heart rate is how they keep track. Change may indicate baby is having problems. Decreased heart rate may also mean there was a short-term decrease in oxygen and baby is compensating well by conserving it. EFM cannot predict baby’s long term well being. When analyzing pattern, one caregiver may deem as fine while other says distress. Has high rate of false positives, where it indicates distress but baby is fine. Nonreassuring heart rate patterns have led to to an increased rate of cesareans but surgery hasn’t reduced number of birth injuries or infant deaths.

In addition to EFM, fetal scalp stimulation is a simple, quick and accurate way to learn more about how baby is handling labor. Caregiver presses on baby’s scalp and if heart rate rises, she’s doing fine; if not, she might not be doing well. Some recommend cesarean quite quickly others are willing to wait to see if pattern improves or doesn’t worsen; these babies are born just as healthy as babies born my immediate cesarean.

 

  1. b) Intermittent vs. continuous fetal monitoring

Studies that compare auscultation and EFM (continuous or intermittent) report each method has similar outcomes. Most caregivers prefer EFM because it monitors many women at same time and frees them from doing it by hand; also saves paper. EFM may limit contact with nurse and may keep you in bed. Auscultation may feel more personal and may work better with your coping strategy.

Caregivers prefer EFM for high risk. If you are healthy and low-risk, shouldn’t have to be monitored continuously. 20 min of EFM when first admitted followed by 15 min each hour is accepted protocol as long as baby’s heart rate remains normal. Also endorsed protocol for 1 minute during and after contraction every 15-30 min in 1st stage and every 5-15 min during 2nd stage.

Check whether hospital uses EFM and if it’s routine for all women; if so, check whether wireless or telemetry is available.

 

Current evidence base of electronic fetal monitoring (EFM) – compared to intermittent auscultation, continuous CTG showed now significant difference in perinatal death but was associated with a halving of neonatal seizures. There was a significant increase in cesareans and assisted vaginal births in continuous group. There were no differences in Apgar scores, neonatal admissions or hypoxic ischemic encephalopathy.

Using #s needed to treat method, one neonatal seizure might be prevented in every 660 cases if all women were continuously monitored. This has to be balanced against the much greater risk of emergency cesarean (1/58 women).

The results have shaped national and local guidelines, which pretty universally recommend continuous CTG for high-risk groups. Does not show any difference in perinatal death and cerebral palsy even in high-risk group. One trial in preterm labors found higher rates of cerebral palsy in latter group and only other study that examined the 2 methods in high-risk women showed no differences in outcome.

Some maternity unites allow intermittent auscultation in particular groups such as induction of labors that don’t require syntocinon. Those who had previous cesareans found a higher vaginal birth rate in intermittent group and higher rates of cesarean for non-reassuring CTG in continuously monitored group without any impact on perinatal outcome.

Makes no sense to install very expensive central bank monitoring system where individual women’s traces can be viewed centrally. Yet many labor wards across the world have invested in this technology.

 

Monitoring the Mobile Woman’s Fetus: seems to be tradeoff between advantages of maternal mobility and presumed advantages of EFM, which can be resolved by discontinuing routine practice of continuous EFM, because it carries virtually no benefit for low risk woman or baby and does have some added risks. For years, it was assumed that continuous EFM improved newborn outcomes, but numerous scientific trials have failed to confirm. Trials found disadvantages, such as increase in cesareans and instrumental deliveries with no improvement in newborn outcomes for woman ant low risk (and not receiving oxytocin)

  • Auscultation – findings of trials above led ACOG and other orgs in 80s and 90s to support or promote intermittent auscultation as either equal to or preferred over EFM for low risk woman with healthy pregnancies. Offer strict guidelines on circumstances that require continuous EFM and/or fetal scalp blood sampling.
  • When EFM is required: options to enhance maternal mobility– EFM has become well established in most hospitals.
  • Continuous EFM– woman does not have to remain in any single position or in bed. May lie on side, sit up, kneel and lean forward, get out of bed and rock in a chair, stand and lean over bed or birth ball on bed, sway or “slow dance” with partner beside monitor, kneel, lunge or even sit in bath. Woman’s support person or mesh garment may hold transducer in place or washcloth may be placed between transducer and its belt so that it will not slip when woman is in standing, hands and knees or other position. Internal scalp electrode has advantage of not slipping out of place when woman rolls over, kneels or squats as external monitor often does. Scalp electrode is more invasive than external ultrasound transducer, requires ruptured membranes and is more likely to promote maternal-fetal transmission of HIV in HIV positive mom; its usually not needed as todays’ ultrasound devices can pick up fetal heart rate well.   When intrauterine pressure catheter (IUPC) is being used, a woman can make use of upright positions, but it requires adjustment of pressure gauge when woman changes positions, in order to maintain accurate pressure readings. One should ask how important it is to record intrauterine pressure and avoid it if there are no compelling clinical reasons to do so.
  • Intermittent EFM– caregiver holds on woman’s belly for a minute at recommended intervals. Heart rate tracing will printout for easier interpretation along with auditory transmission. There are waterproof stethoscopes for those who labor in bath. Ultrasound transducer that comes with electronic fetal monitor can be used while woman is immersed in water. Check with engineering department for assurance there are no dangerous electronics in transducer. If no waterproof Doppler stethoscope available, mother may be asked to rise out of water intermittently for monitoring.
  • Telemetry- if woman must be monitored continuously and birth setting has EFM telemetry unit, woman may walk in or outside room or sit in bath or shower. In wireless telemetry units, both ultrasound transducer and contraction sensor have build-in radio transmitters, which are held on woman’s trunk with elastic belts. All parts are watertight and safe to use in bath/shower. Older radio telemetry system also consists of belts and transducers connected to portable radio transmitter that hangs around mom’s neck, clips to her robe or hangs over side of bath. Check with engineering department to make sure safe in water. Documented benefits of walking and hydrotherapy in speeding slow progress and reducing pain, telemetry may be optimal choice of monitoring methods when continuous monitoring is called for.

May be possible to avoid some of problems caused by immobility and horizontal position that usually accompany EFM. Problems may include OP position, less efficient contractions, supine hypotension (if woman remains on back) and excessive pain.

  1. c) Meconium

Stools – meconium fills the lower intestine at birth. It is formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from mucosa). Meconium is greenish black and viscous and contains occult blood. The 1st meconium stool passed is usually sterile, but within hours all meconium passed contains bacteria. Most healthy term infants pass meconium within the first 12-24 hrs of life, and almost all do sy by 48 hrs. the number of stools passed varies during the first week, being most numerous between the 3rd and 6th days. Newborns fed early pass stools sooner. Progressive changes in the stooling pattern indicate a properly functioning GI tract.

 

Signs of Gastrointestinal Problems – the time, color and character of the infant’s first stool should be notes. Failure to pass meconium can indicate bowel obstruction related to conditions such as inborn error of metabolism (cystic fibrosis) or a congenital disorder (Hirschsprung’s disease or an imperforate anus). An active rectal “wink” reflex (contraction of the anal sphincter muscle in response to touch) is a sign of good sphincter tone.

Fullness of the abdomen above the umbilicus can be caused by hepatomegaly, duodenal atresia, or distention. Abdominal distention at birth usually indicates a serious disorder such as a ruptured viscus (from abdominal wall defects) or tumors. Distention that occurs later can be the result of overfeeding or signal GI disorders. A scaphoid (sunken) abdomen, w bowel sounds heard in the chest and signs of respiratory distress, indicates a diaphragmatic hernia. Fullness below the umbilicus can indicate a distended bladder.

 

Some infants are intolerant of certain commercial infant formulas. If an infant is allergic or unable to digest a formula, the stools can become very soft w a high water content that is signaled by a distinct water ring around the stool on the diaper. Forceful ejection of stool and a a water ring around the stool are signs of diarrhea. Care must be taken to avoid misinterpreting transitional stools from diarrhea. The loss of fluid in diarrhea can rapidly lead to fluid and electrolyte imbalance. Passage of meconium from the vagina or urinary meatus is a sign of a possible fistulous tract from the rectum.

 

The amount and frequency of regurgitation (spitting up) or vomiting after feedings should be documented. Color change, gagging, and projectile (very forceful) vomiting occur in association w esophageal and tracheoesophogeal anomalies.   Vomiting in large amounts, esp if projectile, can be a sign of pyloric stenosis. Bilious emesis is suggestive intestinal obstruction or malrotation of the bowel.

 

Changes in Stooling Patterns of Newborns 

Meconium

  • The infants first stool is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells and possibly blood (ingested maternal blood or minor bleeding of alimentary tract vessels).
  • Passage of meconium should occur within the first 24-48 hrs, although it can be delayed up to 7 days in very low birth weight. Passage of meconium can occur in utero and can be a sign of fetal distress.

Transitional Stools

  • Usually appear by 3rd day after initiation of feeding
  • Greenish brown to yellowish brown; thin and less sticky than meconium; can contain some milk curds

Milk Stool

  • Usually appears by 4th day
  • Breastfed infants: stools yellow to golden, pasty in consistency; resemble a mixture of mustard and cottage cheese, w a odor similar to sour milk
  • Formula-fed infants: stools pale yellow to light brown, firmer consistency, w a more offensive odor

 

Meconium-Stained Amniotic Fluid – fetus has passed meconium (1st stool) before birth. Meconium stained amniotic fluid is green; consistency either thin (light) or thick (heavy), depending on amount. 3 possible reasons: 1) normal physiologic response with maturity (rare before 23-24 wks increased incidence after 38 weeks or with breech) 2) result of hypoxia-induced peristalsis and sphincter relaxation or 3) sequel to umbilical cord compression – induced vagal stimulation in mature fetuses.

Major risk is development of meconium aspiration syndrome (MAS) in newborn. Causes a severe form of aspiration pneumonia that occurs most often in term or post-term infants. Most likely results from long-standing intrauterine process, rather than from aspiration immediately following birth as respirations are initiated.

Care Management – presence of a team skilled in neonatal resuscitation is required at birth of any infant w meconium-stained amniotic fluid. AAP and American Heart Association Neonatal Resuscitation Program no longer recommends routine suctioning of newborn’s mouth and nose on perineum followed by endotracheal suctioning after birth. Instead, based on assessment of baby’s condition at birth. No clinical studies warrant basing tracheal suctioning guidelines simply on meconium consistency.

Immediate Management of the Newborn w Meconium-Stained Amniotic Fluid

Before Birth

  • Assess fluid for presence of meconium after rupture of membranes
  • If meconium stained, gather equipment and supplies that might be necessary for neonatal resuscitation
  • Have at least 1 person capable of performing endotracheal intubation on the baby present at the birth

Immediately After Birth

  • Assess baby’s respiratory efforts, HR, and muscle tone
  • Suction only baby’s mouth and nose, using a bulb syringe or large-bore suction catheter if baby has:
    • Strong respiratory efforts
    • Good muscle tone
    • HR >100 BPM
  • Suction trachea using an endotracheal tube connected to a meconium aspiration device and suction source to remove any meconium present before many spontaneous respirations have occurred or assisted ventilation has been initiated if baby has:
    • Depressed respirations
    • Decreased muscle tone
    • HR <100 BPM

Every birth should be attended by at least 1 person whose only responsibility is the baby and who is capable of initiating resuscitation, including endotracheal suctioning to remove meconium, if necessary.

 

2nd Trimester Changes for You and Baby – “development” period – baby’s organs and structures begin to enlarge and mature.

15th-27th Week

  • Changes in Baby: baby starts to grow hair, eyelashes and eyebrows. Lanugo develops on arms, legs and back. Fingernails and toenails appear. 18 weeks, baby can do all movements you’ll see her do as a newborn. Forming in baby’s intestines is meconium, collection of digestive enzymes and residue from swallowed amniotic fluid; won’t expel til after birth. Skin is wrinkled and covered in vernix caseosa. Feel baby move for first time (quickening). Light tapping/fluttering sensation that reminds you of gas bubbles. Some babies born at end of this trimester (25 weeks) survive. 23 weeks – heartbeat audible via regular stethoscope. 27 weeks eyes are open, begins to hear.
  • Changes in Placenta/Uterus – uterus expands into abdominal cavity to accommodate growing baby. length of pregnancy in weeks approximates distance in centimeters between pubic bone and top of uterus (fundus).   Uterus normally contracts periodically, although wont notice. Braxton hicks contractions make uterus hard for ~1 minute but aren’t painful; don’t cause changes in cervix.

 

Evaluating Your Amniotic Fluid – when membranes rupture, appearance of amniotic fluid can indicate baby’s position. Normal fluid is clear and has a slightly fleshy odor. If strong odor of old fish, may have infection. If fluid green/dark, baby has expelled meconium, which indicates she’s stressed. Presence isn’t uncommon; occurs in 20% of all labors. Caregiver will observe baby’s heart rate frequently.

Ask about protocol for treating newborn who’s expelled meconium. Many suction baby’s nose, mouth and trachea when head is born and before 1st breath; belief is that suctioning prevents baby from inhaling meconium, preventing breathing problems or a rare type of pneumonia called meconium aspiration syndrome; research hasn’t found that aggressive suctioning prevents this. Instead, suctioning seems to cause abrasions in membranes of baby’s mouth and nose.

 

Concerns about Baby’s Well-being

Most healthy full-term babies get a better start in life if they undergo labor. Contractions jump-start many processes that improves a baby’s transition to life outside the womb, such as breathing, temperature regulation, alertness and suckling.

During a contraction, the amount of oxygen that’s available ot the baby varies. Although most compensate well, a few can’t and show signs of distress. EFM of heart rate patterns indicate they’re not getting optimal amount of oxygen during contractions. Described as having nonreassuring fetal heart rate, fetal intolerance of labor or fetal distress.

Presence of meconium may indicate a baby isn’t compensating well for varying amount of available oxygen during contractions. When a baby’s oxygen supply is low, her intestines cramp to send oxygen-rich blood to other areas that need oxygen the most (such as her brain). This cramping causes meconium to pass. When a woman’s bag of water breaks, the caregiver notes the presence of meconium.

Although EFM and presence of meconium don’t always identify oxygen-deprived babies, caregivers won’t hesitate to take measures to improve baby’s well-being if either assessment indicates distress.

What you can do if baby has nonreassuring heart rate pattern – need professional help. Follow caregivers request to change positions, breathe deeply; these measures are often enough to restore baby’s heart rate to normal

Medical Care for Babies in Distress During Labor – sometimes the problem resolves itself without intervention. If baby is pressing on umbilical cord and constricting flow of oxygen-rich blood, he may shift his position so he moves off the cord, thereby restoring normal blood flow.

If intervention is necessary, there are several options to restore a baby’s heart rate to normal. May breathe oxygen by mask and change position to increase baby’s heart rate. If Pitocin is causing contractions too intense, dose can be reduced to slow or stop contractions, increasing amount of available oxygen to baby. if not receiving Pitocin, can receive a tocolytic (anti-contraction) medication to slow or stop contractions and allow oxygen levels (and thus baby’s heart rate) to improve.

If volume of amniotic fluid is too low to cushion the umbilical cord, caregiver may use amnioinfusion, a procedure that replaces enough water in your uterus to remove the pressure on the cord caused by your baby’s head or trunk. If these don’t resolve problem or conditions worsen, cesarean may be necessary.

 

How Body Makes Breast Milk– prolactin and oxytocin two hormones play significant roles. When baby suckles at breast, it stimulates anterior pituitary gland in brain to release prolactin into bloodstream. Prolactin causes cells in alveoli to draw water and nutrients from blood to make milk. Suckling or hear of a cry prompts posterior pituitary gland to release oxytocin. Oxytocin makes muscles around milk-producing cells contract and expel milk. Also makes ducks widen and shorten, helping with milk flow. AKA let down reflex.

2 or more letdowns from each breast during each feeding. In first few weeks, may take several minutes after baby has begun suckling. After good relationship established, happens in seconds. Might not feel let down in first few days. Sensations differ – might not feel it, may feel tingling, itching or flowing.   If don’t feel it, you’ll know it occurred if hear baby swallow, see milk in his mouth or feel uterine cramping.

Frequency and duration of feedings strongly affect milk supply. The more your baby suckles and drains from your breast, the more milk you produce. You make less if you delay or limit feedings, use a pacifier, offer supplements (formula, water or other liquids), or schedule your baby’s feedings to every 3-4 hours due to a protein in breast milk called feedback inhibitor of lactation (FIL). When breast is full of milk, FIL slows milk production. When baby frequently drains, there is less FIL and milk production increases.

To help develop a good milk supply, feed baby frequently (in response to his feeding cues) and let him feed for how long he wants.

  1. d) Variations in birth position and multiples

(1) Multiples

Multiples (Twins, Triplets or More)

Higher risk of complications such as preterm rupture of membranes, preterm labor, preeclampsia, prolonged labor, prolapsed cord and babies who are malpositioned or who are premature or small in size for their gestational age. Labor/birth usually more complicated than birth of a single baby; for example a woman’s overstretched uterus sometimes can’t contract efficiently, which slows labor progress and increases risk of postpartum hemorrhage.

Risk of these difficulties increase as number of babies increase. Expect more medical supervision and more interventions..

Timing is a controversial topic; some believe that waiting until labor starts on its own can affect babies well being – that multiples are born healthier if labor is induced or cesarean is scheduled between 37 and 39 weeks. Studies have found inconsistent results. Others believe physiological process of labor is best for mom and baby.

May recommend epidural in case an intervention that may be painful for mom is needed to deliver 1 or more babies (such as forceps). Although twins often born vaginally at term, rate of cesarean birth for twins is higher than for single babies and rate increases with number of babies. Its rare for triplets or more to be born vaginally at term.

Vaginal birth of twins – ultrasound during labor to identify babies’ presentations. Results determine whether vaginal birth or cesarean birth is best for babies’ well being and your own. If vaginal birth is attempted, it likely occurs in an operating room in case a cesarean becomes necessary.

Most favorable presentation is vertex and in most cases both babies are vertex at time of birth. If both babies are breach, cesarean is performed. If 1st baby vertex and 2nd is breech, caregiver may attempt to turn 2nd baby after vaginal birth of first or 2nd baby may be born breech. Birth of 2nd baby usually occurs within 5-30 min after the first.

 

Multifetal Pregnancy – incidence of twinning is 1/43 births. Steady rise in multiple births since 1973. Partly attributed to availability of assisted reproductive technologies and increasing age at which women give birth as wells as use of ovulation-enhancing drugs.

Dizygotic Twins – when 2 mature ova are produced in 1 ovarian cycle, both have potential to be fertilized by separate sperm. Results in 2 zygotes; always 2 amnions, 2 chorions, 2 placentas that may be fused. These fraternal twins can be same sex or different sexes and are genetically no more alike than siblings born at different times. Dizygotic twinning occurs in families, more often among African-American women than Caucasian women and least often among Asian women. Increases in frequency w maternal age up to 35 yrs, with parity, and w use of fertility drugs.

Monozygotic Twins – identical twins develop from 1 fertilized ovum, which then divides. Same sex and have same genotype. If division occurs soon after fertilization, 2 embryos, 2 amnions, 2 chorions and 2 placentas that can be fused will develop. Most often, division occurs between 4 and 8 days after fertilization, and there are 2 embryos, 2 amnions, 1 chorion and 1 placenta. Rarely, division occurs after the 8th day after fertilization. In this case, there are 2 embryos w/in a common amnion and a common chorion w 1 placenta. This often causes circulatory problems because the umbilical cords may tangle together, and one or both fetuses may die. Monozygotic twinning occurs approx. 3.5-4/1k births. No association w race, heredity, maternal age, or parity. Fertility drugs increase incidence.

Conjoined, or Siamese twins – cleavage is incomplete and occurs late (13-15 days postconception). Estimated frequency 1.5/100k births. Prenatal diagnosis possible w 3 dimensional ultrasonography. Cesarean birth minimizes trauma to mom and fetuses.

Other Multifetal Pregnancies – 3+ fetuses increased w use of fertility drugs and IVF. Triplets ~1/1341 pregnancies. Can occur from division of 1 zygote into 2, w one of the 2 dividing again, producing identical triplets. Or from 2 zygotes, 1 dividing into a set of identical twins and the 2nd developing as a single fraternal sibling, or from 3 zygotes. Quadruplets, quintuplets, sextuplets, have similar derivations.

Nongenetic Factors Influencing Development – congenital disorders may be inherited, may be caused by environmental factors, or may be a result of inadequate maternal nutrition. Congenital means condition was present at birth. Some congenital malformations may be caused by teratogens, that is, environmental substances or exposures that result in functional or structural disability. In contrast to other forms of developmental disabilities, disabilities caused by teratogens are theoretically totally preventable. Known human teratogens are certain drugs and chemicals, infections, exposure to radiation and certain maternal conditions such as diabetes and PKU. A teratogen has greatest effect on organs and parts of embryo during its period of rapid growth and differentiation, which occurs during embryonic period, specifically days 15-60. During first 2 weeks of development, teratogens either have no effect or have effects so severe that they cause miscarriage. Brain growth and development continue during the fetal period, and teratogens can severely affect mental development throughout gestation.

In addition to genetic makeup and the influence of teratogens, the adequacy of maternal nutrition influences development. The embryo and fetus must obtain the nutrients needed from mom’s diet; they cannot tap maternal reserves. Malnutrition during pregnancy produces low birth-weight newborns susceptible to infection. Malnutrition also affects brain development during latter half of gestation and can result in intellectual disabilities in child. Inadequate folic acid associated w neural tube defects.

Milestones in Human Development Before Birth Since Last Menstrual Period

4 weeks/ 8 wks/ 12 wks / 16 wks / 20 wks/ 24 wks/ 28 wks/ 30-31 wks/ 36-40 wks

  • External appearance: body flexed, C-shaped; arm and leg buds present; head at right angles to body/ body fairly well formed; nose flat, eyes far apart; digits well formed; head elevating; tail almost disappeared; eyes, ears, nose and mouth recognizable/ nails appearing; resembles a human; head erect but disproportionately large; skin pale, delicate / head still dominant; face looks human; eyes ears and nose approach typical appearance on gross examination; arm/leg ratio proportionate; scalp hair appears/ vernix casesosa appears; lanugo appears; legs lent then considerably; sebaceous glands appear/ body lean but fairly well proportioned; skin red and wrinkled; vernix caseosa present; sweat glands forming/ lean body, less wrinkled and red; nails appear / subcutaneous fat beginning to collect; more rounded appearance; skin pink and smooth; has assumed birth position / skin pink, body rounded; general lanugo disappearing; body usually plump
  • Crown to Rump Measurement: Weight .4-.4 cm; .4g / 2.5-3 cm; 2g / 6-9 cm; 19g / 11.5-13.5 cm; 100g / 16-18.5 cm; 300g / 23 cm; 600g/ 27 cm; 1100g / 31 cm / 1800-2100g/ 35 cm-40 cm; 2200-3200g+
  • Gastrointestinal System: stomach at midline and fusiform; conspicuous liver, esophagus short, intestine a short tube; intestinal villi developing; small intestines coil within umbilical cord; palatal folds present; liver very large/ bile secreted; palatal fusion complete; intestines have withdrawn from cord and assume characteristic positions / meconium in bowel; some enzyme secretion; anus open / enamel and dentine depositing; ascending colon recognizable
  • Musculoskeletal System: all somites present/ first indication of ossification – occiput, mandible and humerus; fetus capable of some movement; definitive muscles of trunk, limbs and head well represented/ some bones well outlined, ossification spreading, upper cervical to lower sacral arches and bodies ossify, smooth muscle layers indicated in hollow viscera/ most bones distinctly indicated throughout body; joint cavities appear, muscular movements can be detected; sternum ossifies; fetal movements strong enough for mother to feel / astragalus (talus, ankle bone) ossifies; weak, fleeting movements, minimum tone / middle 4th phalanges ossify; permanent teeth primordia seen; can turn head side to side / distal femoral ossification centers present; sustained, definite movements, fair tone, can turn and elevate head; active, sustained movement, good tone, may lift head
  • Circulatory System: heart develops, double chambers visible, begins to beat; aortic arch and major veins completed/ main blood vessels assume final plan; enucleated red cells predominate in blood / blood forming in marrow/ hear muscle well developed; blood formation active in spleen/ nothing written/ blood formation increases in bone marrow and decreases in liver
  • Respiratory System: primary lung buds appear / pleural and pericardial cavities forming; branching bronchioles; nostrils closed by epithelial plugs/ lungs acquire definite shape; vocal cords appear/ elastic fibers appear in lungs; terminal and respiratory bronchioles appear/ nostrils reopen; primitive respiratory-like movements begin/ alveolar ducts and sacs present; lecithin begins to appear in amniotic fluid (weeks 26-27)/ lecithin forming on alveolar surfaces/ L/S ratio = 1.2:1 / L/S ratio =2:1; pulmonary branching only 2/3 complete
  • Renal System: rudimentary ureteral buds appear / earliest secretory tubules differentiating; bladder-urethra separates from rectum/ kidney able to secret urine; bladder expands as a a sac/ kidney in position; attains typical shape and plan / 36 weeks: formation of new nephrons ceases
  • Nervous System: well-marked midbrain flexure; no hindbrain or cervical flexures; neural groove closed/ cerebral cortex begins to acquire typical cells; differentiation of cerebral cortex, meninges, ventricular foramina, cerebrospinal fluid circulation; spinal cord extends entire length of spine / brain structural configuration almost complete; cord shows cervical and lumbar enlargements; forth ventricle foramina are developed; sucking present/ cerebral lobes delineated; cerebellum assumes some prominence/ brain grossly formed; cord myelination begins; spinal cord ends at level of first sacral vertebra (S1); cerebral cortex layered typically; neuronal proliferation in cerebral cortex ends / appearance of cerebral fissures, convolutions rapidly appearing; indefinite sleep-wake cycle; cry weak or absent; weak suck reflex/ nothing written 30-31/ end of spinal cord at level of 3rd lumbar vertebra (L3); definite sleep-wake cycle; myelination of brain begins; patterned sleep-wake cycle w alert periods; strong suck reflex
  • Sensory Organs: eye and ear appearing as optic vessel and octocyst/ primordial choroid plexuses develop; ventricles large relative to cortex; development progressing; eyes converging rapidly; internal ear developing; eyelids fuse/ earliest taste buds indicated; characteristic organization of eye attained/ general sense organs differentiated/ nose and ears ossify/ can hear/ eyelids reopen; retinal layers completed, light-receptive; pupils capable of reacting to light/ sense of taste present; aware of sounds outside moms body
  • Genital System: genital ridge appears (5th week)/ testes and ovaries distinguishable; external genitalia sexless but begin to differentiate/ sex recognizable; internal and external sex organs specific/ testes in position for descent into scrotum; vagina open/ nothing written/ testes an inguinal ring in descent to scrotum/ nothing 28/ testes descending to scrotum/ testes in scrotum; labia majora well developed

 

 

Multifetal Pregnancy – With increased use of assistive reproductive technology and ovulation induction agents, incidence of multifetal pregnancy has risen. In US. Twin birth rate has stabilized at 33.1 / 1000 births. Triplets and higher is 124.4 /10000; a drop from 153.5 in 2009.

Multifetal pregnancy places mother and fetuses at increased risk for adverse outcomes. Maternal blood volume is increased, resulting in an increased strain on maternal cardiovascular system. Anemia often develops because of greater demand for iron by fetuses. Marked uterine distention, increased pressure on adjacent viscera and pelvic vasculature, and diastasis of rectus abdominis muscles can occur. Women at increased risk for gestational diabetes, hypertension and preeclampsia. Placenta previa develops more commonly because of large size or placement of placentas. Premature separation of the placenta can occur before the 2nd and any subsequent fetuses are born.

Multifetal pregnancies often end prematurely. Risk of preterm labor and birth increase w number of fetuses. Spontaneous rupture of membranes common. Fetuses likely to experience growth restriction or discordant growth. There can be local shunting of blood between placentas (twin-to-twin transfusion); this causes recipient twin to be larger and donor twin to be small, pallid, dehydrated, malnourished and hypovolemic. However, larger twin can develop congenital heart failure during first 24 hrs after birth. The risk of death of 1 or more fetuses increases significantly w higher order multiples.

If presence of >3 diagnosed, parents may receive counseling regarding selective reduction to reduce incidence of premature birth and improve opportunities for remaining fetuses to grow to term. Poses ethical dilemma for many couples, esp those who have worked hard to overcome problems w infertility and have strong values regarding right to life. Nurses can help them identify resources (priests, ministers, mental health counselor) to aid in decision making.

Likelihood of multifetal pregnancy increased if 1 or combination of following factors is noted:

  • History of dizygotic twins in female lineage
  • Use of fertility drugs
  • More rapid uterine growth for # of weeks of gestation
  • Polyhydramnios
  • Palpation of more than the expected # of small or large fetal parts
  • Asynchronous fetal heartbeats or more than 1 fetal electrocardiographic tracing
  • Ultrasound evidence of more than 1 fetus

Diagnosis of multifetal pregnancy a shock to many parents.

Prenatal care includes changes in pattern of care and modifications in other aspects. Prenatal visits scheduled more frequently. Frequent ultrasounds, nonstress tests, and FHR monitoring will be performed. Mother needs info related to self-management because guidelines differ. Specific instruction regarding nutrition. other about risk of preterm labor and warning signs. Uterine distention associated w multifetal pregnancy can cause backache commonly experienced by pregnant women to be even worse. Maternal support hose may be worn to control leg varicosities. If risk factors such as premature dilation of cervix or bleeding are present, abstinence from orgasm and nipple stimulation during last trimester is recommended to avert preterm labor. Some recommend bed rest at 20 weeks to prevent preterm labor; others question value of prolonged bed rest. If bed rest recommended, mothers assumes lateral position to promote increased placental perfusion. If birth is delayed until after 36th week, risk of morbidity and mortality decreases for neonates.

Multiple newborns can place strain on finances, space, workload and woman and family’s coping capabilities.   Lifestyle changes can be necessary. Parents should be referred to national orgs such as Parents of Twin and Triplets (www.nashvilleparent.com/directories/parents-of-twins-and-triplets-organization-potato), Mothers of Twins (www.nomotoc.org) and LLL.

 

Multifetal Pregnancy – gestation of twins, triplets, quadruplets or more infants. Twins accounted for >3.3% of births in U.S. in 2012. Rate or triplet or higher order multiple births 124.4/100k births, lowest rate in 18 yrs. # of multiple gestation pregnancies dramatically rose in 80s and 90s, most likely due to fertility enhancing medications and procedures as well as more women older than 35 continuing child bearing. When compared w younger women, 35+ naturally more likely to have multifetal pregnancy. Rate of triplet and higher order multiple pregnancies has been steadily declining since all time high rate of 193.5 /100k births in 1998. Decrease attributed to refinements in treatments used for infertility, particularly limiting the # of embryos transferred during in vitro fertilization IVF procedures.

Multiple births associated w more complications (dysfunctional labor) than singleton births. Higher incidence of fetal and newborn complications and higher risk of perinatal mortality primarily stem from birth of low-birth-weight infants resulting from preterm birth or IUGR (or both), in part related to placental dysfunction and twin to twin transfusion. Fetuses can experience distress and asphyxia during the birth process as a result of cord prolapse and the onset of placental separation with the birth of the 1st fetus. As a result the risk for long-term problems such as cerebral palsy is higher among infants who were part of a multiple birth.

Fetal complications such as congenital abnormalities and abnormal presentation scan result in dysfunctional labor and an increased incidence of cesarean birth. 40-45% of all twin pregnancies, both fetuses present in vertex position, the most favorable for vaginal birth. 35-40% of pregnancies, 1 twin can present in vertex and other in breech or transverse.

Health status of mom can be compromised by increased risk for hypertension, anemia, and hemorrhage associated w uterine atony, placental abruption, and multiple or adherent placentas. Duration of phases and stages of labor can vary from duration experienced w singleton births.

Teamwork and planning essential components of management of labor and birth in multiple pregnancies, esp those of higher-order multiples. Nurse plays key role in coordinating activities of many highly skilled health care professionals. Early detection and management of the maternal, fetal and newborn complications associated are essential to achieve a positive outcome for mom and babies. Maternal positioning and active support are used to enhance labor progress and placenta perfusion. Stimulation with oxytocin, epidural, internal or external version, forceps and vacuum may be necessary. Cesarean is almost always performed w higher order multiple births. Each infant has its own team of health care providers present at birth.

Position of Woman – functional relationship among uterine contractions, fetus and mother’s pelvis altered by maternal position. Positioning can provide a mechanical advantage or disadvantage to the mechanisms of labor by altering the effects of gravity and the body-part relationships that are important to the progress of labor.

Discouraging maternal movement or restricting labor can compromise progress. Incidence of dysfunctional labor in women confined to positions is increased, resulting in greater need for augmentation of labor or forceps, vacuum or cesarean birth.

Psychologic Responses – hormones and neurotransmitters released in response to stress (catecholamines) can cause dysfunctional labor. Sources vary but pain and absence of support person often related to dysfunctional labor. Confinement to bed and restriction of maternal movement can be a source of psychologic stress that compounds physiologic stress caused by immobility in unmedicated laboring woman. When anxiety excessive, can inhibit cervical dilation and result in prolonged labor and increased pain perception. Anxiety also increases levels of stress related hormones (beta-endorphin, adrenocorticotropic hormone, cortisol, and epinephrine). These hormones act on the smooth muscles of the uterus. Increase levels can cause dysfunctional labor by reducing uterine contractility.

(2) Breech Birth

Self-Techniques to Turn a Breech Baby– By 34-36 weeks, baby should assume his birth position. Effectiveness hasn’t been formally studies; others have been studied and found ot be mostly ineffective. But pose few if any risks. Even in success is low, try may decrease risk of cesarean

  • Breech Tilt Position –hips 10-15 inches higher than head. Exaggerated open knee chest or hands and knees with buttocks high in air. 10 min 3x a day, when baby is active. To ease discomfort, make sure your stomach and bladder are empty. Try to relax abdominal muscles and visualize baby somersaulting so her head is in position over your cervix. May feel baby squirm as her head presses into the top of your uterus (fundus)
  • Use of sound– during active phases, babies can hear well and often respond to sounds. By playing pleasing or familiar sounds low in uterus, baby may move head down to hear. Can play through headphones placed just above pubic bone. Partner can talk to baby.
  • Use of cold on fundus – if area becomes uncomfortable cold, baby may move head. Makes sure to have a layer of cloth between ice pack and skin. No longer than 20 min at a time

Complementary Medicine Methods

  • Acupuncture – Urinary Bladder 67, located on outside tip of each little toe. Can also use moxibustion; some reports show success rate for turning breech by onset labor 50%
  • Webster technique – analysis of mom’s pelvis, adjustment of her sacrum and relief of abdominal muscle tension. Goal is to relieve any uterine constraint that may be preventing baby from moving into a favorable birth position. Hasn’t been formally studies but popularity is growing. icpa4kids.com

 

Soft-Tissue Injuries – Erythema, ecchymoses, petechiae, abrasions, lacerations and edema of the face, head buttocks and extremities can be present. Localized discoloration can appear over presenting or dependent parts. Ecchymoses and edema can appear anywhere on the body and esp on the presenting part from application of forceps or vacuum. Can also result from manipulation of infant’s body during birth.

Bruises all over the face can be the result of face presentation. In a breech presentation, bruising and swelling can occur over the buttocks or genitalia. The skin over the entire head can be ecchymotic and covered w petechaie caused by a tight nuchal cord. Petechiae, or pinpoint hemorrhagic areas, acquired during birth can extend over the upper portion of the trunk and face. These lesions are benign if they disappear w/in 2 days of birth and no new lesions appear. Eccymoses and petechiae can be signs of a more serious disorder, such as thrombocytopenic purpura, if the hemorrhagic areas do not disappear spontaneously in 2 days.

 

To differentiate hemorrhagic areas from skin rashes and discolorations such as Mongolian spots, the nurse blanches the skin w 2 fingers. Because extravagated blood remains w/in the tissues, petechiae and ecchymoses do not blanch.

Forceps injury occurs at site of application of instrument. Forceps injury typically has a linear configuration across both sides of the face, outlining the placement of the forceps. The affected areas are kept clean to minimize the risk of secondary infection. These injuries usually resolve spontaneously w/in several days w no specific therapy.

Accidental lacerations can be inflicted w a scalpel during cesarean birth or w scissors during an episiotomy. These cuts can occur on any part of the body but most often are found on scalp, buttocks and thighs. Usually they are superficial, needing only to be kept clean. Butterfly adhesive strips or topical skin adhesive will usually hold together the edges of more serious lacerations. Rarely are sutures needed.

2 of the most commonly occurring birth injuries are subconjuctival (scleral) and retinal hemorrhages. These injuries result from rupture of capillaries caused by increased intracranial pressure (ICP) during birth. They usually clear w/in 5 days after birth and present no problems; however, parents need reassurance about their presence.

Caput succedaneum and cephalhematoma are commonly seen in neonates, often as the result of pressure on the fetal head pushing through a dilated cervix.

A more serious injury is subgaleal hemorrhage, which is bleeding into the subgaleal compartment. The subgaleal compartnment is a potential space that contains loosely arranged connective tissues; it is located beneath the galea aponeurosis, the tendinous sheath that connects the frontal and occipital muscles and forms the inner surface of the scalp. The injury occurs as a result of forces that compress and then drag the head through the pelvic outlet. This can occur w mild forceps birth and vacuum extraction. The bleeding extends beyond bone, often posteriorly into the neck, and continues after birth, with the potential for serious complications such as anemia, hypovolemic shock, or even death. Early detection of the hemorrhage is vital; serial head circumference measurements and inspection of the back of the neck for increasing edema and a firm mass are essential.   A boggy scalp, pallor, tachycardia and increasing head circumference can be early signs of a subgaleal hemorrhage. Another possible early signs is a forward and lateral positions of infant’s ears because hematoma extends posteriorly. Infants w risk factors for subgaleal hemorrhage, including those born by forceps or vacuum should have head circumference monitored per unit protocol for up to 48 hrs after birth or longer if head circumferences is increasing. Monitoring the infant for changes in level of consciousness and a decrease in hematocrit is also key to early recognition and management. An increase in serum bilirubin levels can be seen as a result of the breakdown of blood cells within the hematoma. Computed tomography (CT) or magnetic resonance imaging (MRI) is useful in confirming diagnosis. Replacement of lost blood and clotting factors is required in acute cases of hemorrhage if bleeding continues and infant’s condition deteriorates, neurorsurgery may be needed.

Skeletal Injuries – difficult delivery of shoulders w a vaginal birth or extension of arms in breech birth often results in clavicular fracture (Clavicle is bone most often fractured during birth; generally break is in middle third of the bone).

 

Skeletal System – at birth more cartilage is present than ossified bone. Because of cephalocaudal (head-to-rump) development, the newborn looks somewhat out of proportion.

Head at term is approx. ¼ of total body length. Arms are slightly longer than legs. Legs are about 1/3 of total body length.

Face appears small in relation to the skull.

Caput Succeedaneum – generalized easily identifiable edematous area of scalp, most commonly found on occiput. Usually disappears within 3-4 days. Infants born w vacuum have caput in area where cup was applied.

Cephalhematoma – collection of blood between a skull bone and its periosteum. Firmer and more well defined than a caput. Often occur simultaneously. Usually resolves 2-8 weeks. As hematoma resolves, hemolysis of RBCs occurs and hyperbilirubinemia can result.

Subgaleal Hemorrhage – bleeding into the subgaleal compartment. Commonly associated w difficult operative vaginal birth, esp vacuum. Blood loss can be severe, resulting in hypovolemic shock, disseminated intravascular coagulation.

Early detection of hemorrhage is vital; serial head circumference measurements and inspection of the back of the neck for increasing edema and a firm mass are essential. Boggy scalp, pallor, tachycardia and increased head circumference can be early signs of subgaleal hemorrhage. Computed tomography or MRI useful in confirming diagnosis. Replacement of lost blood and clotting factors required in acute cases of hemorrhage. Another possible early sign is a forward and lateral positioning of newborn’s ears because hematoma extends posteriorly. Monitoring infant for changes in level of consciousness and decreases in hematocrit is also key to early recognition and management. Increase in serum bilirubin may be seen as a result of degradation of blood cells within the hematoma.

Spine – bones in vertebral column on newborn form 2 primary curvatures – 1 in thoracic region and 1 in sacral region. Both forward, concave curvatures. As infant gains head control at ~3 months, secondary curvature appears in cervical region. Newborn spine appears straight and can be flexed easily. Newborn can lift head and turn from side to side when prone. Vertebrae should appear straight and flat. If a pilonidal dimple is noted, further inspection required to determine whether a sinus is present. A pilonidal dimple, sp w a sinus and nevus pilosis (hairy nevus) can be associated w spina bifida.

 

 

Extremities – should by symmetric and equal length. Fingers and toes equal in number, should have nails present. Digits may be missing (oligodactyly). Extra digits (polydactyly) sometimes. Figures or toes may be fused (syndactyly).

Infant examined for developmental dysplasia of hips (DDH). Affected hip unlikely to be dislocated at birth; instead easily dislocatable. Postnatal factors determine whether hip dislocates, subluxates or remains stable. DDH occurs more often in female infants, in breech presentation, and in infants w family history of DDH.

Signs of DDH are asymmetric gluteal and thigh skinfolds, uneven knee levels, positive Ortolani test and positive Barlow tests. Hips inspected for symmetry. Gluteal and thigh skinfolds should be equal and symmetric and legs of equal length. Level of knees in flexion should be equal. Hip integrity assessed by using Barlow test and Ortolani maneuver. For Barlow test, examiner places middle finger over greater trochanter and thumb along midthigh. Hip flexed to 90 degrees and adducted, followed by gentle downward pushing of the femoral head. If hip can be dislocated w this maneuver, the femoral head moves out of the acetabulum, and examiner feels a “clunk.” Hip is then checked to determine if femoral head can be returned into the acetabulum using the Ortolani maneuver. As hip is abducted and upward leverage is applied, dislocated hip returns to acetabulum w a clunk that is felt by examiner.

Only expert examiners should perform Barlow test and Ortolani maneuver to assess for DDH. Unskilled can cause injury.

 

  • (3) External version

External Version – 37-38 weeks but some consent earlier on an experimental basis. Studies show it’s a safe procedure with a ~65% success rate.

  • Baby receives stress test before and after
  • Using ultrasound, confirms breech, estimates volume of amniotic fluid, visualizes uterus, cord and site of placenta and plans direction in which to move baby. it isn’t done if volume if low or you have uterine abnormalities. Procedure may be avoided if placenta is implanted in front wall of uterus
  • Receive an injection of a tocolytic drug (such as terbutaline), which relaxes uterus. Make may you feel a little nervous or shaky
  • Caregiver presses and pushes on baby through abdominal wall, encouraging him to turn to a vertex presentation

Takes 5-10 min. if baby’s heart rate shows distress, procedure is stopped. If placenta begins to separate from uterine wall during procedure (rare) or if baby remains in distress after it’s stopped, may need cesarean.

May only take a nudge or two or may require constant pressure. Try to relax ab muscles and use light breathing. If you need a break, say so. Caregiver can hold baby in place until you’ve caught breath.

Caregiver may offer epidural or spinal block for comfort. Unclear whether anesthesia presents more risks that not using it; it prolongs the procedure and recovery time and its expensive.

  • (4) Webster technique
  • 
(5) Complimentary medicine methods

Other Treatments for PPD – hormone therapy (often combined w antidepressant medication), complementary or alternative therapies, and ECT. Complementary and alternative medicine (CAM) therapies are increasingly being used by people w psychiatric disorders. Several commonly used CAM therapies (bright light therapy, exercise, massage, repetitive transcranial magnetic stimulation and acupuncture) are considerations in treatment of perinatal depression. # of these treatments may be reasonable to consider for women during pregnancy or postpartum, but safety and efficacy of these relative to standard treatments must still be systematically determined.

ECT may be used for women w PPD who have not improved w antidepressant therapy. Psychotherapy in the form of group therapy or individual (interpersonal) therapy has been used w positive results alone and in conjunction w antidepressant therapy; however, more studies are needed to determine what types of professional supports are most effective. Repetitive transcranial magnetic stimulation is a new therapy for PPD, but more studies need to be done to demonstrate the efficacy. Alternative therapies may be used alone but often are used w other treatments for PPD. Safety and efficacy studies of these alternative therapies are needed to ensure that care and advice are based on evidence.

St. John’s wort is often used to treat depression; has not been proven safe who those breastfeeding.

 

Complementary and Alternative Measures – most herbal remedies have not been proven clinically to promote fertility or to be safe in early pregnancy. Women should take these only when prescribed by a physician, nurse midwife or nurse practitioner who has expertise in herbology. Relaxation, osteopathy, stress management (aromatherapy, yoga), and nutritional and exercise counseling have increase pregnancy rates in some women. Integrative mind-body-spirit programs for teaching attitudes of kindness, flexibility, curiosity, acceptance and openness effectively decrease stress and anxiety related to infertility in women. Antioxidant vitamins E and C, selenium, zinc, coenzyme Q10, and ginseng have shown beneficial effects for male infertility.

Medications and Herbal Preparations – although much has been learned in recent years about fetal drug toxicity, the possible teratogenicity of many medications, both prescription and OTC, is still unknown. This is esp true for new medications and combinations of drugs. Moreover, certain subclinical errors or deficiencies in intermediate metabolism in the fetus may cause an otherwise harmless drug to be converted into a hazardous one. The greatest danger of drug-caused developmental defects in the fetus extends from the time of fertilization through the 1st trimester, a time when the woman may not realize she is pregnant. Self-treatment must be discouraged. The use of all drugs, including OTC medications, herbs and vitamins, should be limited and a careful record kept of all therapeutic and nontherapeutic agents used.

The use of CAM by pregnant women is widespread. There is limited research evidence about the safety of herbal preparations, esp during pregnancy. Although the use os CAM therapies is consistent w the holistic, woman-centered approach to care, caution is warranted in their use because of the lack of evidence related to their safety and efficacy.

Although CAM may benefit the woman during pregnancy, some practices should be avoided because they can increase risk for complications. Important to ask woman about OTC products (including herbals and vitamins) she is using.

 

Birth Options for a Breech Baby– although vaginal breech births usually result in healthy babies, it carries risks. May increase risk of prolapsed cord or even spinal cord injury, a rare problem that can occur if baby’s head is tilted back (hyperextended) when passing through birth canal. Another potential risk is compressed cord. During vaginal breech birth, baby’s feet and body are born before head. As baby’s head comes through, it can compress cord and reduce amount of oxygen in blood coming from placenta. Because baby’s feet and buttocks are smaller than her head, they may be born before cervix dilates enough for her head to pass through, in this event, birth of her head may be delayed, causing distress.

  • Because of potential of complications, cesareans have become routine in U.S. since 70s. Fewer caregivers learned skills to conduct them. In 2000, influential study found that breech babies born by cesarean had better outcomes. Recent criticisms of story.
  • In other parts of world, vaginal breech births are common. In Europe and Australia, they are routine.

Can screen for breech babies then plan vaginal births for them. When practicing this guideline, half born vaginally, the number of complications decrease markedly and both mom and baby fare well.

If attempts to turn breech baby are unsuccessful by 37-38 weeks, time to consider planned cesarean.

  1. Active labor
  2. a) Non-medical ways to encourage active labor

 

Prolonged Active Labor – in 1st stage, early phase is prolonged if it takes longer than usual for cervix to dilate to 4-5 cm and enter active phase. Usually resolves with time, self care and changes to environment that reduces stress and increase body’s release of oxytocin.

In active labor, cervical dilation speeds up, contractions become more painful and labor progresses with each contraction. If labor slows or stops in this phase, it may indicate problems with mom or baby.

Prolonged active labor can result from a number of things affecting mother: full bladder, medications, immobility, ineffective contractions, baby in unfavorable position, dehydration and lack of nourishment, exhaustion or stress caused by environment, discouragement, anxiety of fear

Self-Help Measures to Speed Up Active Labor – way to speed it up depends on cause

  • Full bladder – empty every hour or so
  • Medications – allow time to let them wear off, if it’s safe to do so
  • Immobility – walk or stand to let gravity help baby descend. Shift from lying on one site to sitting or hands and knees
  • Ineffective contractions – Acupressure, nipple stimulation, walking, standing
  • Unfavorable position – try to improve
  • Dehydration – drink plenty of fluids and eat food that gives you energy, if allowed
  • Exhaustion/stress – reassurance, encouragement, safe and nurturing environment, comfort measures and relaxation techniques

 

Prolonged Labor – address epidemic of exogenous oxytocin augmentation.

The Labor Progress Handbook promotes options other than the traditional medical approaches of AROM and oxytocin augmentation. Series of postural and positional options that may stimulate labor and a number of accompanying comforts/support measures like application of hot towels to lower back.

Organizational “dystocias”

  • Lack of continuity of care and continuous support
  • Inexperienced doctors at start of their rotation
  • Absence of expertise during summer holidays, weekends, night shifts, bank holidays
  • Disagreements between midwife and OB
  • Inadequate handovers because of fatigue of intimidation

Advantage of hydrotherapy over an oxytocin infusion in nulliparous women. Research showed those women who entered birthing pools when labor slowed ultimately received less augmentation (71% vs 96%) and fewer epidurals (47% vs 66%) than those who were medically management w syntocinon. Water immersion shortens labor. Findings suggest that every labor ward should have, alongside sundry ampoules of oxytocin and packs of disposable amniohooks, birth pools available.

Encouraging mobility and posture change also shortens labor. Acupuncture, acupressure, hypnosis, yoga and massage and nipple stimulation may also shorten labor.

For the small # of women who have a pathological prolonged labor due to position problem or poorly defined ‘inordinate uterine contractions’, ARM has for decades been first option for medical management. ARM does not shorten labor, even in nulliparous women and may contribute to higher cesarean rate. Other recourse is oxytocin augmentation, though there is uncertainty in effectiveness in achieving spontaneous vaginal birth, concluding it only does so in 51% of women diagnosed w dystocia. Also link w poor neonatal outcome. ACOG advises only using minimum amount possible to establish and advance labor.

Diagnosis of dystocia is poorly delineated and understood. It needs decoupling from labor plateaus where uterus is just resting and from latent phase that can extend to 5-6 cm dilation. A group remains that may have a positional problem, those will ill-defined incordinate uterine contractions and those that have a true dystocia for whom an oxytocin infusion will not be effective. Lactic acid levels in women with prolonged labor may help distinguish those likely to respond to oxytocin and those who will not.   Dystocia is probably over diagnosed and over treated in Western world.

  1. b) Medical care for prolonged active labor

The Invaluable Birth Doula – don’t overlook services a birth doula can provide. Unlike nursing staff who must concentrate on completing clinical tasks while providing care, a doula can focus solely on you and your partner. She’ll know your birth plan, likes and dislikes, hopes for birth and pain medication preferences. One woman without a partner hired a doula. Another woman whose mother had died wanted feminine energy of someone who had given birth. Another wanted someone to help her and her partner with comfort measures.

Some couples hire a doula just as much for the partner as for laboring woman, especially if partner isn’t completely comfortable with demands of labor support and needs a guide or helper, or wants someone to take over the role of primary support person. Doula can provide backup support if partner has medical condition such as hypoglycemia (which necessitates getting regular food and rest), becomes queasy at sight of blood, has physical limitations or simply wants to avoid pressure of having to learn and remember all comfort measures.

Can also do necessary tasks for partner so they can focus on primary support such as run errands, fetch food, beverages and comfort items such as ice packs. Can take photos, report progress and developments to couple’s friends and family. Can massage woman’s back while partner helps her maintain rhythm or can continue support so partner can eat, get some air or take much needed nap.

If doula isn’t available or allowed in birthplace (or don’t want one), trusted relatives or friends can do many of the things a doula can do, especially if they attend childbirth prep classes with you and partner.

Contingency Plan – if struggling to cope but still don’t want to receive drugs, ideas to try:

  • Change environment. Take a walk, shower, dim lights or put on relaxing music
  • Change ritual or breathing techniques
  • Eat something or drink a sugary beverage. Sometimes all you need is quick energy boost
  • Find out how far cervix has dilated. Labor may be difficult because you’re making rapid progress
  • Don’t base decision on pain medication on one hard contraction. Find new comfort technique for 4-5 contractions. Endorphins may kick in and may make it manageable.

 

Medical Care for Prolonged Active Labor – if both tolerating delay, there may be time to let problem resolve itself or determine cause and intervene as necessary.   Additional vaginal exams likely to check for progress in cervical dilation and in baby’s descent or rotation. May receive IV fluids to prevent or treat dehydration. Caregiver may rupture membranes or administer Pitocin.

If at birth center or home, transfer to hospital becomes necessary if you need Pitocin or if baby isn’t tolerating labor well. It’s the most common reason for transfer to hospital.

If monitoring shows baby is not tolerating well, or if labor continues to lag after Pitocin, cesarean may be necessary.

  1. c) Ways to encourage changes in baby position

Slow Active Labor Caused by Baby’s Position – one of most common reasons (malposition). 25% of women begin labor with baby in OP – baby’s head towards back. Can prolong labor because baby’s head must rotate further than usual to face mom’s front or OA, favorable position for birth. When baby is OP, cervical dilation and baby’s descent might not progress efficiently.

By transition stage, most OP babies have turned to OA position on their own, although some turn after. When low in birth canal, some OP babies are turned by caregiver, who reaches inside vagina and rotates baby’s head to OA; this has a significant success rate. Other babies are born in OP (sunny side up) or by cesarean.

If baby is OP or malpositioned (Such as brow/face presentation), may have considerable back pain because baby’s head is pressing unevenly on sacrum, straining sacroiliac joints. May also occur if baby is transverse.

Back pain or prolonged active labor is sometimes caused by a subtle malposition called asynclitism, in which baby’s head is tilted and the top of it isn’t centered on the cervix. The head doesn’t press evenly on cervix, which makes dilation less efficient and it doesn’t fit through pelvis as well. When baby’s head is tilted, part of head that emerges first is larger than normal. Its difficult to diagnose in labor because it’s not as clearly associated with back pain as OP. clues include delayed dilation or uneven dilation – cervical lip. Another clue is a swollen cervix that seems to have closed a few cm. After birth of head, its shape is also a clue (off center elongation)

What You Can Do If Baby is Malpositioned – can be difficult to identify position. Assume baby is malpositioned if labor progress has slowed, you have back pain or if have irregular or coupling contractions. Try different positions. Once baby’s head fits into pelvis, back pain often subsides and labor progress improves.

 

  1. d) Unexpected pain in labor/ pain vs. suffering

Why Labor is Painful

  • Reduced oxygen to uterine muscles during contraction, which creates a buildup of waste products such as lactic acid, that in turn causes pain
  • Stretching of the cervix as it dilates
  • Pressure of the baby on nerves in and near the cervix and vagina
  • Tension and stretching of ligaments of uterus and pelvic joints during contractions and baby’s descent
  • Pressure of baby on urethra, bladder and rectum
  • Stretching of pelvic floor muscles and vaginal tissues during birth

Your Perception of Pain – simply understanding they physical reasons helps many women cope. Labor pain is normal and temporary. By changing the way you think of pain, you can alter perception of it and reduce its severity.

Gate Control Theory of Pain – helps explain why people feel more pain in some cases and les sin others and why some people feel it more than others. Think of following experiences: stubbed toe that hurts less when you dance, a bruise that goes unnoticed until after game, pain of physical exertion eased when you focus on a rhythm (counting, chanting or singing a song in your head)

Although pain never goes away, your awareness of it decreases when brain receives other stimuli that are non-painful or pleasant (pain modifiers). Helps explain why distractions help relieve pain. Can make pain more manageable during labor by increasing pleasant stimuli (massage, music, cold packs, heating pad or other distractions and focusing on them).

Neuromatrix Theory of Pain – expansion of Gate Control Theory and takes into account all possible factors that can influence how pain is felt and interpreted. Helps explain why women differ in reactions to labor pain and why some women find comfort measures more helpful that others. Past experiences of pain or trauma are factors, as are preexisting factors such as chronic pain or painful medical conditions, anxiety, personality or temperament, physiological factors such as central nervous system’s and endocrine system’s reactions to stress and cultural or familiar attitudes toward pain. Some of these are genetically determined; others are formed earlier in life.

Factors That Increase Labor Pain:

  • Physical: hunger/thirst, fatigue, muscle tension, full bladder, discomfort from staying in same position
  • Emotional/Mental: fear, anxiety, loneliness, or feeling watched or judged (all can release stress hormones); lack of confidence and preparation; ignorance or misinformation about labor/birth; unsupportive staff or relatives; feeling powerless to make decisions or feeling that your decisions aren’t being respected
  • Variations during labor: frequent long contractions or coupling contractions; baby that’s malpositioned; prolonged, tiring labor; exhaustion; rapid intense labor, with little breaks in between contractions; expectations for labor and birth that don’t match actual experience; hospital policies/procedures/interventions that limit mobility or ability to use coping techniques

Measures that make labor pain more manageable – to minimize factors that increase labor pain, be aware of them in advance, make plans to manage them and ensure that your support people are aware of them and work to minimize their impact on you: eat and drink enough to stave off hunger and thirst; dim lights and arrange for minimal interruptions; if have past trauma, get counseling before

Think of what comforts you: what comforts you when sick, what did parents do to make you feel better, what do you do during physical exertion to keep going, what soothes pain of headache/sore muscles, what helps you feel safe in unfamiliar situations, what calms you when stressed/scared, what kind of support from others best helps you. Download worksheet from PCNguide.

Pain vs Suffering in Labor: pain is a mild to unpleasant physical sensation that might or might not be associated with physical damage; suffering is a debilitating emotional state that might be associated with pain or with another cause, such as grief, humiliation or defeat. Can have pain without suffering (strenuous workout). Suffering includes: perceived threat to body/psyche, helplessness and loss of control; distress; inability to cope with distressing situation; fear of dying or death of baby

If don’t have enough stimuli that help reduce perceptions of pain (massage, movement, baths, encouraging words) or if have too many factors increasing it (fear, loneliness, ignorance of what’s happening, immobility, unkind/insensitive treatment, anxiety/depression), more likely to be overwhelmed by pain and feel as if suffering.

Rating Intensity of Pain and Ability to Cope – Pain intensity scale vs pain coping scale

Releasing Control in Labor vs Losing Control – although you can’t consciously control your contractions, you can control how you respond to them. To help avoid feeling discounted, passive, powerless, learn about options for childbirth well before they begin. Read about interventions you are considering and make sure decisions are reflected in birth plan

 

The Psychoemotional State of the Woman: Maternal Well-Being or Maternal Distress?

The Psychoemotional State of the Woman: Maternal Well-Being or Maternal Distress?

Pain vs Suffering

Pain is unpleasant bodily sensation that one wishes to avoid/relieve. Suffering is a distressing psychological state that includes feelings of helplessness, fear, panic, loss of control and aloneness. It’s an inability to cope with pain that is at root of the concern. Women say pain affecting behavior (losing control, crying out, writhing, showing weakness or behaving shamefully) and whether they will find themselves in a state of helplessness. Suffering is similar in definition to trauma and can lead to emotional distress (even PTSD) that sometimes continues long after birth.

2 main approaches to pain management: medication & nonpharmacologic methods

Women asked periodically to assess pain; woman offered medication if it reaches certain level.

More important than assessment of pain is assessment of ability to cope with it.   Can use visual scale or ask after contraction “could you tell me what was going through your mind during that contraction” – her answer will indicate whether she is coping, in distress or both. If coping, all she needs is patience, encouragement and approval. If in distress (crying out, whimpering, struggling or giving up) or has lost rhythm, or if answer indicates emotional distress, it may lead to suffering and she will need intensive emotional/physical support and guidance in different comfort measures to recover a sense that she can cope. If she cannot response to more intensive guidance, she is probably a candidate for pain meds. No woman should remain in a state of suffering.

Labor progress and prevention of dystocia depend on harmonious interactions among a variety of psychoemotional, interpersonal, physical and physiologic factors. Progress is facilitate when a woman feels safe, respected, and cared for by caregivers; when she can remain active, mobile and upright; and when pain is adequate and safely managed. Sense of wellbeing enhanced by caring attentive partner or loved ones; and a calm comfortable and well-equipped birthplace.

Hormones oxytocin, endorphins, catecholamines and prolactin have specific effects; its that balance of hormones that determines net effect on labor progress as well as maternal postpartum mental health, mother-infant interaction, and initiation of breastfeeding.

When neocortex (newer, more uniquely human part of brain – the thinking, reasoning part) is overstimulated, birth process is inhibited. Birth involves coordinated activity within endocrine system and older, more primitive parts of brain that humans share with other mammals.   So minimize stimulation of neocortex. Other mammals seek privacy in comfortable, cozy, quiet space with dim light. In today’s maternity facilities, neocortex constantly stimulated with birth lights, strangers, many questions, unfamiliar sights and sounds and other disturbances inhibiting primate brain function and contributing to dystocia.

 

The hormones of labor and their functions in labor and early post partum:

  • Oxytocin- hormone of “calm and connection” or “love” hormone, contributes to uterine contractions, the urge to push, and fetal ejection reflex, letdown of breastmilk, maternal behavior and feelings of well-being and love. Has opposite effects of catecholamines
  • Endorphinsmorphine like hormones increase with pain, exertion, tress and fear and counteract unpleasant feelings. Create trance-like state in labor (withdrawn, dreamy and instinctual behavior). Contribute to high feelings that many unmedicated women have after birth. Once stress/pain ends, woman has leftover euphoric effects of endorphins
  • Catecholamines stress hormones (adrenalin or epinephrine, noradrenalin or norepinephrine, cortisol and others) secreted when a person is frightened/angry, in danger or feels she is in danger. Hormones of “fight or flight”. Physiologic effect enables person’s body to endure, defend against, or flee a dangerous situation. Counteract effects of oxytocin and endorphins. 1st stage labor contractions may slow down/stop, fetal heart rate may slow, woman becomes tense, alert, fearful and protective of unborn child. Recent studies of female behavior show its better described as “tend and befriend” – protecting offspring and reaching out for support.   In 2nd stage, surge of catecholamines is physiologic and helps mobilize strength, effort and alertness needed to push out baby
  • Prolactin- “nesting hormone” prepares breasts for breastfeeding during pregnancy and after birth; promotes synthesis of milk and has mood-elevating and calming effects on mother. Seems to play a role in altruistic behavior of new mother – ability to put baby’s needs before her own

*Fetus/newborn also produce these hormones, which contribute to fetal well-being during labor, neonatal adaptation, initiation of breastfeeding etc

The “fight-or-flight” and “Tend-and-befriend” responses to distress and fear in labor

“Fight or flight” response is a physiologic process that promotes survival of endangered or frightened animal/human and is triggered by outpouring of catecholamines or stress hormones. Triggered by physical danger, fear, anxiety or other forms of distress, it has potential of slowing labor progress. During most of 1st stage, excessively high levels of circulating catecholamines cause maternal blood to be shunted away from uterus, placenta and other organs not essential for immediate survival to the heart, lungs, brain and skeletal muscle, the organs essential to fight or flight. Decreased blood supply to uterus/placenta slows uterine contractions and decreases availability of oxygen to fetus.

Fear/anxiety also causes woman to interpret caregivers’ words or labor events in a pessimistic or negative way. High levels of catecholamines prevent woman from entering instinctual mental state, sometimes called “the zone”

As woman nears 2nd stage of labor, which requires alertness and great physical effort, outpouring of catecholamines normally occurs and has beneficial effect of speeding birth by causing fetal ejection reflex. Many women briefly exhibit fear, anger or even euphoria, typical catecholamine responses, just before birth.

Although physiology of fight or flight response is similar in men and women, behavioral differences exist between the two sexes. Males’ responses follow fight or flight pattern (fight to protect self, family, village or country against dangerous attackers, or flee from danger if odds are too great), females’ behavioral responses characterized by pattern of “tend and befriend” which refers to protecting their young from harm and reaching out for help or affiliating with others to reduce risks to themselves and their offspring. Women want and need supportive people around them during labor. In face, absence of this kind is one of the most frequently mentioned reasons for later dissatisfaction with childbirth and is associated with ptsd after childbirth. A woman’s protectiveness toward her child is evident when she is told by a respected caregiver that her baby is in danger. She will quickly agree to whatever treatment is suggested; however, if she does not trust caregiver, she may try to protect child by resisting suggested treatment.

Maternal Effects of Anxiety (Tend and Befriend Response) in Labor

Excessive maternal catecholamine levels in 1st stage of labor:

  • Physiologic response in mother: decreased blood flow to uterus, suppression of oxytocin effects, decreased uterine contractions, increased duration of 1st stage of labor, decreased blood flow to placenta
  • Maternal psychological response: increased negative or pessimistic perception of events and words of others, increased need for reassurance and support, protectiveness toward fetus
  • Physiologic response in fetus: increased fetal production of catecholamines, fetal conservation of oxygen, fetal heart rate decelerations

Excessive catecholamine levels in 2nd stage labor:

  • Maternal effects: alertness, renewed energy and strength
  • Fetal effects: same as listed above; fetal ejection reflex (rapid expulsion of fetus)

To enhance woman’s feelings of security/trust and reduce likelihood of emotional distress:

  • Environment for birth: hospital is an alienating environment for most women, in which institutionalized routines and lack of privacy can contribute to feelings of loss of control. Women more likely to labor out of bed and avoid common OB interventions in environments designed to promote normal birth
  • Psychoemotional measures:
    • Before labor, what caregiver can do: encourage women to think about comforting things she and her partner might have during labor – fav music, scents, pictures, loved ones or a doula, hew own clothing to wear during labor, visualizations, aromatherapy, massage or relaxation techniques. Encourage parents to write birth plan, introducing selves and describing concerns, fears, preferences and choices.
    • During labor: tips for nurses and midwives, esp if meeting woman for first time:
      • Introduce self by name and call her by her name. greet her and her support team. Introduce her to unit (room, lighting, use of bed, bath/shower, call buttons, kitchen, nurses station, lounge)
      • Ask her about plans and preferences
      • Encourage atmosphere of privacy, comfort and intimacy between her and support people:
        • Knock before entering, keep door closes
        • Do not leave body exposed
        • Share comfort devices available (ice pack, hot pack, warm blankets, birth ball, beanbag chair, bath, shower, squatting bar, birth stool, music tapes, juices, tea, others)
        • Encourage cuddling, hugging, slow dancing
        • Encourage and reassure woman and try to remain with her as much as she wishes and as much as other responsibilities allow
      • Explain clinical procedures/tests. Giver her results, if woman’s vital signs, labor progress and fetal heart rate appear normal, tell her
      • Inform her of signs of progress as you identify them (6 ways)
      • Suggest comfort measures
      • Reassure her not only with words but also praise, smiles, touch, hand-holding, gestures of kindness/respect

Physical Comfort Measures – may reduce woman’s stress and likelihood of labor-slowing fight or flight response:

  • Create atmosphere (privacy, no sudden noises, dim light) that encourages woman’s spontaneous self-comforting behaviors and those learned in childbirth class
    • Relaxation techniques/rhythmic movements
    • Calming vocalizations (moans, sighs)
    • Rhythmic breathing
    • Guided imagery/visualization
  • Give her partner suggestions
    • Massage and pressure techniques
    • Timing contractions or counting breaths to help her know where she is in contraction
    • Encourage rhythm in movements, breathing, moaning and even in mental activities
    • Wiping her face and neck with cool damp cloth
    • Giving words of praise and encouragement
    • Speaking rhythmically in a soothing low tone of voice
  • Encourage use of available amenities
    • Hot/cold packs
    • Bath/shower
    • Birth ball
    • Cold/hot beverages, ice chips
    • Lounge
    • Music player, TV

The “fight-or-flight” and “Tend-and-befriend” responses to distress and fear in labor

“Fight or flight” response is a physiologic process that promotes survival of endangered or frightened animal/human and is triggered by outpouring of catecholamines or stress hormones. Triggered by physical danger, fear, anxiety or other forms of distress, it has potential of slowing labor progress. During most of 1st stage, excessively high levels of circulating catecholamines cause maternal blood to be shunted away from uterus, placenta and other organs not essential for immediate survival to the heart, lungs, brain and skeletal muscle, the organs essential to fight or flight. Decreased blood supply to uterus/placenta slows uterine contractions and decreases availability of oxygen to fetus.

Fear/anxiety also causes woman to interpret caregivers’ words or labor events in a pessimistic or negative way. High levels of catecholamines prevent woman from entering instinctual mental state, sometimes called “the zone”

As woman nears 2nd stage of labor, which requires alertness and great physical effort, outpouring of catecholamines normally occurs and has beneficial effect of speeding birth by causing fetal ejection reflex. Many women briefly exhibit fear, anger or even euphoria, typical catecholamine responses, just before birth.

Although physiology of fight or flight response is similar in men and women, behavioral differences exist between the two sexes. Males’ responses follow fight or flight pattern (fight to protect self, family, village or country against dangerous attackers, or flee from danger if odds are too great), females’ behavioral responses characterized by pattern of “tend and befriend” which refers to protecting their young from harm and reaching out for help or affiliating with others to reduce risks to themselves and their offspring. Women want and need supportive people around them during labor. In face, absence of this kind is one of the most frequently mentioned reasons for later dissatisfaction with childbirth and is associated with PTSD after childbirth. A woman’s protectiveness toward her child is evident when she is told by a respected caregiver that her baby is in danger. She will quickly agree to whatever treatment is suggested; however, if she does not trust caregiver, she may try to protect child by resisting suggested treatment.

 

Maternal Effects of Anxiety (Tend and Befriend Response) in Labor

Excessive maternal catecholamine levels in 1st stage of labor:

  • Physiologic response in mother: decreased blood flow to uterus, suppression of oxytocin effects, decreased uterine contractions, increased duration of 1st stage of labor, decreased blood flow to placenta
  • Maternal psychological response: increased negative or pessimistic perception of events and words of others, increased need for reassurance and support, protectiveness toward fetus
  • Physiologic response in fetus: increased fetal production of catecholamines, fetal conservation of oxygen, fetal heart rate decelerations

Excessive cathecholamine levels in 2nd stage labor:

  • Maternal effects: alertness, renewed energy and strength
  • Fetal effects: same as listed above; fetal ejection reflex (rapid expulsion of fetus)

Penny Simkin on pain vs. suffering (3:45)

Women wanting to participate more actively in birth. She put together comfort measures to use in labor. Pain of labor doesn’t have to rule labor and overwhelm women. If has medications, takes away feeling of birth/ hormonal process.

Pain vs suffering – pain a physical sensation; suffering is a sense of being overwhelmed, not in control. Can have suffering w out pain. In childbirth, many women suffer because not kindly treated, respected, don’t know anything to do for themselves, feel unloved or alone, which can turn pain into suffering.

No women should suffer in childbirth.

www.comfort-measures.com; www.pennysimkin.com

(2) Fear of birth:

 

To enhance woman’s feelings of security/trust and reduce likelihood of emotional distress:

  • Environment for birth: hospital is an alienating environment for most women, in which institutionalized routines and lack of privacy can contribute to feelings of loss of control. Women more likely to labor out of bed and avoid common OB interventions in environments designed to promote normal birth
  • Psychoemotional measures:
    • Before labor, what caregiver can do: encourage women to think about comforting things she and her partner might have during labor – fav music, scents, pictures, loved ones or a doula, hew own clothing to wear during labor, visualizations, aromatherapy, massage or relaxation techniques. Encourage parents to write birth plan, introducing selves and describing concerns, fears, preferences and choices.
    • During labor: tips for nurses and midwives, esp if meeting woman for first time:
      • Introduce self by name and call her by her name. greet her and her support team. Introduce her to unit (room, lighting, use of bed, bath/shower, call buttons, kitchen, nurses station, lounge)
      • Ask her about plans and preferences
      • Encourage atmosphere of privacy, comfort and intimacy between her and support people:
        • Knock before entering, keep door closes
        • Do not leave body exposed
        • Share comfort devices available (ice pack, hot pack, warm blankets, birth ball, beanbag chair, bath, shower, squatting bar, birth stool, music tapes, juices, tea, others)
        • Encourage cuddling, hugging, slow dancing
        • Encourage and reassure woman and try to remain with her as much as she wishes and as much as other responsibilities allow
      • Explain clinical procedures/tests. Giver her results, if woman’s vital signs, labor progress and fetal heart rate appear normal, tell her
      • Inform her of signs of progress as you identify them (6 ways)
      • Suggest comfort measures
      • Reassure her not only with words but also praise, smiles, touch, hand-holding, gestures of kindness/respect

Physical Comfort Measures – may reduce woman’s stress and likelihood of labor-slowing fight or flight response:

  • Create atmosphere (privacy, no sudden noises, dim light) that encourages woman’s spontaneous self-comforting behaviors and those learned in childbirth class
    • Relaxation techniques/rhythmic movements
    • Calming vocalizations (moans, sighs)
    • Rhythmic breathing
    • Guided imagery/visualization
  • Give her partner suggestions
    • Massage and pressure techniques
    • Timing contractions or counting breaths to help her know where she is in contraction
    • Encourage rhythm in movements, breathing, moaning and even in mental activities
    • Wiping her face and neck with cool damp cloth
    • Giving words of praise and encouragement
    • Speaking rhythmically in a soothing low tone of voice
  • Encourage use of available amenities
    • Hot/cold packs
    • Bath/shower
    • Birth ball
    • Cold/hot beverages, ice chips
    • Lounge
    • Music player, TV

 

Indicators of emotional dystocia during active labor:

  • Express or display fear, anxiety or exhaustion
  • Lack rhythm and ritual in her responses to contractions
  • Ask many questions, ore remain very alert to her surroundings
  • Exhibit very “needy” behavior
  • Display extreme modesty
  • Exhibit strong reactions to mild contractions or to examinations
  • Show a high degree of muscle tension
  • Appear demanding, distrustful, angry or resentful toward staff
  • Seem hypervigilant, highly alert, “jumpy,” or easily startled
  • Exhibit a strong need for control over caregivers’ action
  • Seem “out of control” in labor (in extreme pain, writhing, panicked, screaming, unresponsive to suggestions or questions intended to help)
  • Express fear that she will lose control as labor becomes more intense
  • She may not exhibit any external behaviors that would lead one to consider emotional dystocia

Predisposing factors for emotional dystocia – she probably can’t simply “step out of it”; may result form preexisting factors:

  • Previous difficult births
  • Previous traumatic hospitalizations
  • Childhood abuse or neglect: physical, sexual or emotional
  • Dysfunctional family of origin (mental illness, substance abuse, fighting parents etc)
  • Fears about current serious health problems for herself or baby
  • Domestic violence (previous or present)
  • Cultural factors, including beliefs leading to extreme shame when viewed nude or when viewed in labor by men or when behaving in a way that is contrary to cultural expectations
  • Language barriers, or inability to hear or understand what is happening or being done
  • Death of her own mother (esp in childbirth or at a young age)
  • Beliefs resulting from what she has been told about labor ( ex. Sibling handicapped by birth injury or whose mom had a terrible time giving birth to her)
  • Helping woman state her fears: ask what was going through head during contraction, how woman is feeling right now or if she has any idea what may be slowing labor

Helping the woman state her fears – “What was going through your mind during that contraction?” “How are you feeling right now?” or “Do you have nay idea why your labor is slowing down?” she may indicate any of following fears or others, which could interfere with labor progress:

  • Exhaustion
  • Dread of increasing pain
  • Fear of damage or disfigurement to her own body, including
  • Stretching, episiotomy, tears, stitching or a cesarean and “never being the same again”
  • Fear or uterine rupture, if she has had a cesarean before
  • Fear that labor will harm her baby (a belief that cesarean is safer and easier for baby)
  • Fear of loss of control, of modesty or of dignity; acting like a fool or losing face (shame)
  • Fear of invasive procedures, such as vaginal exams, injections, blood tests or others
  • Fear of her caregivers, many or all of whom may be unknown to
  • Her (she may perceive them as strangers who have power and authority over her)
  • Fear of being unable to care for her baby adequately, of being a “Terrible mother”
  • Fear of abandonment by baby’s father, her caregiver or others
  • Fear of dying (brief transient period of fear or dying in late 1st stage, associated with surge of catecholamines and “fetal ejection reflex” is not unusual, and it is not associated with dystocia). Deep prolonged persistent fear throughout pregnancy and labor is what is referred to here

How to help a laboring woman in distress:

  • Provide language interpreters and culturally competent or culturally sensitive caregivers
  • Restate what she has said to check that you understand (it sounds as if you’re afraid of what the labor might do to your baby. is that right?) if woman confirms:
    • Validate her fears, rather than dismissing it. “Yes, other woman have told me they are scared of that too” “That must be frightening. We’re also concerned about babies during labor and that’s why we check baby’s heartbeat frequently”
    • Provide reassuring info “As I listen to heartbeat, he sounds just fine right now. Would you like to know how babies adapt to contractions during labor? They have some really amazing coping mechanisms”
  • Observe her affect and behavior during conversations and elicit further concerns or needs
  • Between contractions, let her know that after baby is born, there are helpful resources. If woman is worried about being inadequate mom, there are parenting classes and support groups and a hotline she can call any time. Helping her recognize that labor is not time to address fears about parenthood, while also reassuring her that she will not be alone with her concerns, may ease her anxiety enough that labor progress will resume; calming conscious fears may help her enter a more relaxed state in which primitive parts of brain will predominate
  • Provide ideas that woman can use to alter situation. If woman feels helpless lying down, she might feel stronger standing up and active
  • Visualization and reframing can be powerful tools to help a woman overcome her fear. If she is concerned about “poor baby’s head being forced through that tiny opening” she can help to imagine “little baby nuzzling his head own in that soft stretchy place” (describe ripe cervix and vagina as being as soft and stretchy, like inside of cheek when she presses inside it with tongue)
  • If woman unable to cope with overwhelming physical sensations, she may benefit from massage, hydrotherapy or pain medication

Special needs of childhood abuse survivors:

A woman who was sexually or physically abused as a child may have great anxieties in labor, esp related to:

  • Invasive procedures that remind her of abuse, such as: vaginal exams, instruments and fingers placed in the vagina, blood draws or IV lines
  • Lack of control: as a child she was hurt when she was out of control and vulnerable. She may have learned never to lose control
  • Modesty, nakedness, exposure issues
  • Powerful authority figures (midwives, nurses, doctors) who know more than she and who do painful things to her: as a child she was a victim of those with authority over her
  • Being asked to “relax, surrender, or yield to the contractions” with the promise that it will not hurt so much: she may have been told similar things during the abuse
  • Pushing her baby out of her vagina: the pain and prospect of damage may remind her of sexual abuse.

Sometimes an abuse survivor seems difficult or demanding when she responds very emotionally or angrily in above situations. Important to not take it personally and keep in mind woman has very good reason to react the way she does and caregiver is not the reason. Try to be patient, kind and listen to her and to meet her special needs to extent possible, even if they seem unusual or unreasonable. If she feels emotionally safe, her labor may progress more normally and may reap other psychological benefits as well.

 

Anxiety or distress in labor

Anxiety or distress in labor: “emotional dystocia” -à check psychosocial history; comfort measures (bath/shower, massage/soothing touch, breathing/relaxing), psychological interventions (what’s going through mind, reassurance/education, visualizations), kindness/respect, accommodate women’s special needs as possible, patience, doula -à improved labor progress OR rest with narcotics and/or epidural (depending on phase) à oxytocin, AROM à cesarean section

Incompatibility or poor relationship with staff: have discussion with staff member or person’s superior explain differences of opinion. Sometimes all woman needs is to be listened to, respected, and taken seriously so she may be able to trust people around her.

Sometimes simplest solution is to change to someone else. No need for blame, only recognize incompatibility. (Less of problem in UK where continuity of caregiver is in place)

Doula can provide extra psychological support.

If source of woman’s anxiety cannot be identified: ask “Could you tell me what was going through your mind during that contraction?” ask “Anything else” acknowledge stress, reassure her, address her fear, hold her hand and help her and partner with self-comforting measures. Women who expressed distress in early labor were more likely to have longer labors, more fetal distress and all interventions that go along with these problems. If alleviated early in labor, these damaging effects may be prevented. Your influence on mind-body connection in labor may be greater than you think.

 

Signs of emotional distress in 2nd stage:

  • Verbal or facial expressions of fear
  • Crying or panic
  • Inability to get beyond holding back to releasing the pelvic floor
  • Holding her legs together
  • Diffuse bearing down
  • Begging caregiver to teak baby out or knock her out with drugs
  • Desperation, inability to follow caregivers suggestions

Triggers of emotional distress unique to 2nd stage:

  • Fatigue or exhaustion, which can lead to hopelessness or anxiety
  • The intense sensations of 2nd stage or of manual stretching of vagina. These sensations may be esp. frightening if woman has been sexually abused or otherwise traumatized in genital region in past, as may trigger flashbacks
  • Fear of behaving inappropriately or offensively (making noise, passing stool while pushing)
  • The immediacy of the birth and the responsibility of parenting the child, esp fi her own parents were dysfunctional or she has relinquished a child for adoption or had a child removed from her care
  • Fear for baby’s well-being esp if a sibling or previous child died around birth or had another adverse outcome
  • Loss of privacy, sense of modesty when surrounded by strangers watching her perineum
  • Previous cesarean during 2nd stage
  • Thoughtless or unkind treatment by loved ones or caregiver during labor

Common response to fears in 2nd stage is extreme tension in pelvic floor as to deter fetus’s descent, while pushing. Woman may be pushing hard but not effectively. Sometimes she unintentionally and unconsciously contracts her pelvic floor muscles and buttocks as she pushes with her diaphragm and ab muscles. Tension in perineum and constriction of anus while pushing indicate woman is holding back.

(Don’t confuse excessive and prolonged pelvic tension with normal confusion many woman have when they first begin to push; esp true for those without strong urge to push – may be best for them to rest and await a stronger urge).

If woman exhibits “diffuse pushing” and does not benefit from measures to improve her bearing down efforts, consider possibility of emotional dystocia.

Whatever fears/anxieties cause woman to hold back, she prob cannot simply “snap out of it”

  • Encourage woman to express feelings. Ask “What was going through mind during last contraction??” listen to her, acknowledge and validate her concerns and try to give appropriate reassurance, encouragement or info and suggestions. Often, all woman needs is a chance to express her concerns. She needs to know she is being heard, fears are normal, and she will get through this event. Even normal evens can be very troublesome to anxious women
  • Sometimes, when it’s clear to everyone including woman, that there is a delay, asking her why she thinks labor has slowed down reveals useful info. “I cant push right” or “Baby doesn’t want to come out” might indicate emotional dystocia
  • Provide appropriate info. If woman is afraid of having bowel movement – she can be reassured passing stool indicates she is pushing effectively, its common and any fecal material will be quickly wipe away and disposed of. One of many good reasons to apply warm compresses to perineum at this time
  • If she’s afraid she will rip or split apart, reassure her by relaxing perineum or letting baby come, her perineum will actually stretch better and tear is less likely. Unless there’s a good reason not do to so, let her try a few contractions without pushing. Lets try breathing through this next one, so she feels she has options
  • Give woman time to adjust to intense sensations/emotions of 2nd Avoid creating a sense of rushing. No need for a caregiver to raise voice
  • Encourage woman to relax perineum between contractions and let it bulge during contractions. Application of hot compresses (washcloths soaked in warm water, wrung out) to perineum often feels good and promotes relaxation. Encourage woman to push as if blowing imaginary balloon, or if she were trying to urinate rapidly. Give her positive reinforcement whenever she bears down effectively. Pushing in this manner sometimes causes pelvic floor to bulge. If she seems reluctant to sustain bearing-down effort and she’s not making progress, advise her to “push to the pain, and right through it. It will feel better when you push through it”
  • Have woman try pushing while sitting on toilet. If she’s worried about passing stool, toilet is a reassuring place to be. Toilet sitting also elicits conditioned response or releasing pelvic floor. If woman feels baby is coming, she will need to move to more appropriate delivery site

 Fear in Childbirth (4:04) 6-10% report disabling fear of childbirth

What do woman fear?

  • Lack of strength to cope
  • Well being of baby
  • Not being able to breathe
  • Not being able to push
  • Losing control of their physical bodies
  • Lack of support from family and friends
  • Previous emergency cesareans, negative birth experience and conflict with care providers
  • Disempowerment
  • “ A pregnant woman with intense fear of giving birth runs a considerable risk of negative experiences of labor and feelings of dissatisfaction after childbirth”
  • Pain medication does not improve satisfaction of birth experience
  • Fear of childbirth ahs been reported as a common reason for requesting elective cesarean
  • Some women believe a cesarean will give them a level of control with which they equate with safety
  • Research states that cesarean births are not safer than vaginal births for both mother and baby
  • Health care providers must educate women about risks and benefits of cesareans
  • “The gap between perceived knowledge and actual knowledge is a concern, as it suggests that women may not be truly participating in informed decision-making”
  • “The experience of childbirth should be considered more important than the mode of delivery”
  • “Positive expectations during pregnancy are associated with positive experiences of giving birth”
  • Health care providers need to understand women’s fears in order to support them

What factors reduce woman’s’ fears?

  • Support provided through relationships with healthcare professionals
  • Support provided through relationships with partners, family and close friends
  • Continuity of care
  • Antenatal counseling
  • We need to “foster a sense of uniqueness in the ability and capacity of the human female body to grow and birth a healthy baby”

(3) PCN Pgs 182-188 Options for Pain Relief – essential to have a “toolbox” of coping options :

  • Coping skills you’ve used throughout life to comfort yourself when sick, tired, worried, in pain or physically exerting yourself;
  • Self help skills you practice during pregnancy such as breathing techniques, relaxation, visualization and attention focus
  • Comfort items to bring to birthplace such as own pillow or clothes, snacks and beverages, heating pads, cold packs, birth ball, shower/bathtub
  • Hands on support from doula/partner – massage, gentle stroking, acupressure
  • Changes to environment to make it more comfortable such as dimming lights, playing music, aromatherapy, asking for minimal disruptions

Availability of Pain-Relief Options – options depend on where you give birth. If birth at birth center, won’t have access to epidural. Hospital policies care practice and available equipment might/might not support various comfort techniques such as eating, mobility, baths/showers, birth balls, acupuncture and aromatherapy. Anesthesiologist may not be available at all times

Effectiveness of Various Pain Relief Options % used, % helpful

  • Epidural 76%, 81%
  • Bathtub 6%, 48%
  • Massage 20%, 40%
  • Iv narcotics 22%, 40%
  • Birth ball 7%, 34%
  • Heat/cold 6%, 31%
  • Relaxation 25%, 28%
  • Position changes 42%, 23%
  • Changes to environment 4%, 21%
  • Breathing techniques 49%, 21%

Although pain medications – especially epidural – can effectively minimize or eliminate pain, they’re also expensive and carry risks and disadvantages that may complicate labor. Consider trying various nun drug methods first to see if they can help you manage effectively. Even if planning to receive epidural or pain meds, still wise to know comfort techniques to cope on way to hospital or while waiting for pain medication.

Determining Your Preferences for Pain Relief – do you prefer to give birth without drugs or do you prefer to use medications? How strongly do you feel about this? May be influenced by past experiences or expectations about labor.   Better able to cope if have info on all available options. More likely to avoid, postpone or minimize if you have a partner or doula who encourages you and helps with self-help comfort measures, supportive staff, caregiver who’s patient/encouraging. The more uncomplicated your labor, the better your chances for non-medicated labor. If labor is prolonged, complicated or includes painful interventions, you’re more likely to need medications.

Pain Medication Preference Scale – PMPS

Being Flexible with Plan for Pain Relief – labor may progress faster than expected, leaving no time for medications or you may be one of unlucky few for whom medications don’t provide adequate pain relief. Partner should remember pain medication preference. If plan to delay, he/she should suggest trying another coping technique for 4-5 contractions before helping you get drugs. Can also use a code word

Preparing to Labor without Pain Medications – if having drug free labor is your goal

  • Confirm partner agrees with goal and helping you achieve it
  • Choose birthplace that supports non-medicated birth and has non-medical tools such as birth balls and large bathtubs. Choose caregiver experienced in supporting women without pain medications. Ask what percentage of clients use pain meds
  • Learn comfort techniques
  • Take childbirth prep classes
  • Consider hiring a doula
  • State wishes in birth plan
  • Avoid/minimize interventions that can increase labor pain (induction and augmentation) or ones that limit mobility (EFM)
  • Consider having code word
  • As move from early labor to active (305 cm), contractions will become painful. Try to adapt breathing, movements or activities to help cope. When cervix dilates 6-7 cm, contraction may become intense. if you can relax between contractions and maintain a rhythm, you’ll be coping well. As move from active labor to transition (7-8 cm), may need to rely on support. Partner can remind you contractions are as painful as they’ll become. If have gone this far, can probably manage rest of labor without pain meds
  • Note to Partners – stay hydrated and keep up energy by eating nutritious snacks.   Conserve strength when physically supporting partner. Use good body mechanics.

 

Common medications used for pain relief during labor -Effects and side effects vary for all, depending on drug, total dosage, timing, baby’s condition and your reaction. See PCNGuide

Systemic Medications

IV Narcotics or Narcotic-like Analgesics

  • How/When Given: IV by direct injection or injection into an IV line. Sometimes, patient controlled analgesia (PCA) used. Can also be given by IM injection. Given in early to active labor, when it’s believed birth is at least 2 hours away. Also give after cesarean
  • Drugs Used: morphine, fentanyl (sublimize), meperidine (Demerol), butorphanol (Stadol), nalburphine (Nubain); stadol and nubain are combination drugs which contain a narcotic antagonist to lessen side effects
  • Benefits: during active labor, drugs reduce awareness of pain and promote relaxation between contractions. Large doses of narcotics (esp morphine) may be used in a prolonged prelabor in hopes of slowing or stopping contractions and allowing you to rest.
  • Possible Risks:
    • You: itching, nausea, vomiting, drowsiness, hallucinations, dizziness or feeling of being high; may lower heart rate, respiratory rate and BP; may affect ability to use self-help comfort measures; may temporarily slow labor progress
    • Baby: may make heart rate readings appear normal; after birth may slow breathing or alter behavioral responses (poor suckling) for several days
  • Additional Precautions/Interventions: possible restriction to bed/IV fluids; frequent monitoring of BP and baby’s heart rate; frequent reminders for you to breathe deeply and help to keep you oriented; narcotic antagonists, if needed to reduce side effects; changes in your position or admin of oxygen to improve baby’s heart rate pattern; discontinuation of medications at least 2 hours before birth to reduce side effects on baby; oxygen and resuscitation equipment on hand if baby is born within 4 hours after narcotics given
  • Additional Systemic Medications Less Commonly Used in Labor
    • Sedatives and barbiturates such as Nembutal or Phenobarbital, which are given by pill/injection; used for anxiety or in larger doses to help you sleep during a slow, painful prelabor. May be used before 4 cm dilation but should be discontinued before active labor to reduce effects on baby. rarely used in U.S. and Canada
    • Tranquilizers such as Phenergan, Versed or Valium given by pill or injection. Used for anxiety in early labor or following a cesarean. Not used in active labor because effect on newborns
    • Inhalation analgesia (nitrous oxide), inhaled through mask. Doesn’t eliminate pain but effects on mental state mean you’re less troubled by pain. Drug is rapidly metabolized, which means few or no side effects on baby. rarely used in U.S. but common in Canada
    • Narcotic antagonists such as Narcan, which are given by injection in labor if narcotic medication is causing adverse side effects of by injection into newborn with breathing problems caused by narcotics given shortly before birth
    • General anesthesia, in which induction agent given by IV, then inhalation agent inhaled through mask. Causes unconsciousness as well as complete numbness. Used in less than 10% cesarean births.

Local Anesthetics

Local Perineal Block

  • How/When Given – by injection around vaginal opening; in 2nd stage, before episiotomy or in 3rd stage for repair of episiotomy or tear
  • Drug Used– Lidocaine (most often)
  • Benefits – numbness in perineum; relief of pain during crowning, episiotomy or stitching after the birth
  • Possible Risks – injections may sting; if given during 2nd stage, may increase swelling in perineum and increase likelihood of vaginal tears. Minimal to no risks to baby
  • Additional Precautions and Interventions– postpose until after birth and use only if stitches necessary
  • Additional Local Anesthetics Less Commonly Used
    • Pudendal block, given by injection deep into vagina. Numbs vagina and perineum during birth. Rarely used except with forceps delivery
    • Paracervical block, given by injection into cervix. Numbs cervical pain and pressure in lower uterus. Given between 5-9 cm. rarely used, because of effects on baby.

Neuraxial Medications (Epidural or Spinal)

Epidural Analgesia with Combination of Narcotics and Anesthetics

  • How/When Given– epidural catheter; given in active labor until birth
  • Drugs Used – combination of narcotic and a “-caine” anesthetic
  • Benefits – decreased pain and numbness (or reduced sensation) in abdomen, back and perineum; increased ability to relax/sleep; mental clarity
  • Possible Risks– reduced mobility, drop in BP, fever, discomforts such as itching, nausea and vomiting, slowed labor progress, decreased urge to push, which may lead to forceps or vacuum delivery; spinal headache caused by epidural needle that has been inserted too far (2% chance), secondary side effects from precautions
    • Baby: same as for IV narcotics although milder; worrisome changes to heart rate pattern, fever
  • Additional Precautions and Interventions– restriction of food/drink, IV fluids, bladder catheter, restriction to bed, various devices to closely monitor you and baby.
    • As needed: oxygen by mask, Pitocin to speed labor, episiotomy, vacuum, forceps, cesarean, blood patch for spinal headache (small amount of blood injected in epidural space near dural puncture), additional medications to control itching/nausea
      • If baby showing effects – same as IV narcotics
      • If baby born with fever – admittance to special care nursery for 48 hours for observation and antibiotics; septic workup to check for infection (blood test and spinal tap)

Spinal (Intrathecal) Narcotic Analgesia

  • How/When Given– spinal injection, early to active labor
  • Drugs Used – narcotic only
  • Benefits – decreases perception of pain; allows for ability to move freely in bed. May be able to stand with assistance; still feel sensations other than pain (touch, pressure, temp), when compared to iv narcotics, receive more pain relief with less medication. Effects last up to 2 hours
  • Possible Risks– itching, nausea, vomiting; weakness in legs or loss of balance while walking; possible altered mental state, but less so that with IV narcotics and narcotic-like analgesics; spinal headache (less than 1% chance)
    • Baby: same as for IV narcotics, though effects milder
  • Additional Precautions and Interventions– if have spinal headache, blood patch; lying flat for hours/days
    • If baby showing effects of narcotics, same as for IV narcotics

Combined Spinal- Epidural (CSE)

  • How/When Given– spinal injection as early as 2cm with addition of anesthetic at 5-8cm
  • Drugs Used – spinal narcotics given first; epidural analgesia given when needed
  • Benefits – same as for spinal narcotics and epidural analgesia
  • Possible Risks– same as for spinal narcotics and epidural analgesia
  • Additional Precautions and Interventions– same as for spinal narcotics and epidural analgesia

Spinal Block

  • How/When Given– spinal injection; used for planned cesarean
  • Drugs Used – -“caine” drugs
  • Benefits – total numbness from chest to toes, although you may still feel some pressure or pulling during the delivery of your baby. provides excellent pain relief without impairing your mental awareness. Can be administered quickly and takes effect almost immediately. Effects last a few hours.
  • Possible Risks– drop in BP, occasional feeling of being unable to breathe (because chest becomes anesthetized); spinal headache (1% chance)
    • Baby: fetal distress, subtle neurobehavioral effects for day
  • Additional Precautions and Interventions– same as for spinal narcotics and epidural analgesia plus assisted ventilation if breathing difficulties arise

Summary of Normal Labor without Pain Medications (if plan to have epidural, use this until receive epidural)

Prelabor

  • Physical Changes: cervix begins to ripen, efface and move forward. Have nonprogressing contractions and may have restless back pain, soft bowel movements and menstrual like cramps; may last for days
  • How you may feel/respond: tired, discouraged, anxious. May be unable to sleep through contractions. May overestimate labor progress, start rituals and go to birthplace. May focus more than necessary on contractions.
  • Ways To Cope: engage in distracting activities and projects; alternate distracting activities with restful ones such as taking a bath, listening to music, lying down, having a massage etc; use labor-stimulating measures (only if you feel pressured to get into labor); eat if hungry (carbs), drink to thirst
  • Ways Partner/Doula Can Help: review route to birthplace; encourage you to eat/drink; pack vehicle and make sure there’s fuel; time contractions (5-6 at a time) every few hours or when labor seems to have changed; ensure you aren’t left alone; help make the time pleasant for you; alert your doula to be ready to come when you need her if she’s not already with you; enhance emotional security and reduce stress by creating a soothing, safe, private and loving atmosphere

First Stage of Labor: Early Labor

  • Physical Changes: denotes time from onset of labor until cervix is dilated 4-5 cm; contractions are progressing, usually mild at first, then becoming longer, stronger and closer together; cervix continues ripening, effacing and begins to dilate; may have bloody show; membranes may rupture (10% chance) but this usually happens later in labor; may have back pain with contractions
  • How you may feel/respond: same as in prelabor plus have mixed feelings – excitement, confidence, and optimism or anxiety and distress – often at same time; as contractions intensify, you can no longer be distracted by them
  • Ways To Cope: begin using planned rituals (relax, breathe, and focus through each contraction) when intensity of contractions stops you from doing distracting activities; use slow breathing, releasing tension with each exhalation; ask doula for help; contact caregiver or birthplace as instructed when contractions have reached 4-1-1 or 5-1-1 pattern; comfort measures for back pain
  • Ways Partner/Doula Can Help: continue timing contractions periodically; call caregiver or birthplace when contractions reach designated intensity, frequency and length or if membranes ruptured; focus on your contractions as soon as you begin doing a planned ritual; give you constructive feedback, not false praise; help you release tension in a selected area of your body with each exhalation; remind you of positions and comfort techniques

First Stage of Labor: Getting into Active Labor

  • Physical Changes: cervix dilated 4-5 cm; contractions intensify and occur every 3-4 min, lasting 1 min or longer; labor progress should begin to speed up at 5 cm
  • How you may feel/respond: head for birthplace or call midwife; may struggle to remain in control and worry that labor is too hard and long; may become serious, withdrawn, and focused on your labor; may recognize that labor isn’t within your control, leaving you feeling trapped – you may weep; you can no longer be distracted during contractions, you need partner or doula’s undivided attention during them; find unnecessary conversation annoying; may want pain meds; can release control and accept your labor if you can move freely, feel safe and uninhibited and have good support
  • Ways To Cope: try to release your need to be in control; let labor happen as you discover what helps you cope (finding your spontaneous ritual); maintain a rhythm with your breathing and movements, letting your partner or doula help as necessary; try to continue slow breathing if you find it restful; remember that labor progress should speed up soon; if planned for early epidural, can probably receive it during this phase
  • Ways Partner/Doula Can Help: drive to birthplace carefully!; use massage (hand or foot), double hip squeeze, counterpressure, slow dancing etc; rhythmically murmur soothing, encouraging words to you; guide you with visualizations, imagery, rhythmic talk or breath-counting – whatever helps you respond well; help you keep a rhythm in your breathing, moaning, swaying, tapping or whatever action you choose; refrain from asking questions during contractions and ask only simple yes or no questions between contractions; help with your ritual (stroking you, holding you, talking to you through contractions) or simply stay by you if that’s all you require; help you follow preferences on pain meds

First Stage of Labor: Active Labor

  • Physical Changes: cervix dilates from 5-8cm; lasts on average 3-5 hours; if baby is OP or her head is tilted to 1 side, dilation of cervix may pause as baby corrects position; may have back pain (30% chance)
  • How you may feel/respond: calmer than before, now that you’ve discovered how to get through contractions; may enter birth zone and become aware or little other than labor
  • Ways To Cope: same as for early labor and getting into active labor plus – take a bath for relaxation and pain relief; stay hydrated by taking frequent sips of water/juice
  • Ways Partner/Doula Can Help: same as for getting into active labor plus stay by you side, offer you liquids, remind you to empty your bladder

First Stage of Labor: Transition

  • Physical Changes: cervix dilates from 8-10 cm; baby begins to descend toward vaginal opening; contractions are long and close together; pain and intensity of labor at its max; lasts less than 2 hours or less than 1 if given birth before; as cervix completes dilation, may have a lip that remains
  • How you may feel/respond: scared/lost; angry/frustrated; may want more help from others; may feel you’ve reached your limit; may lose rhythm and ritual; may cry out, tense, weep or protest; may feel hot, then cold; may tremble; may feel nauseated; may vomit
  • Ways To Cope: Keep a rhythm; follow partner/doula’s lead with Take Charge Routine; Hang in there! ; if want an epidural, can do it at this time as long as labor isn’t moving too fast
  • Ways Partner/Doula Can Help: maintain a confident, calm, optimistic manner; keep eye contact with you; Take Charge Routine; remind you that transition means you’re almost ready to push out baby; hold you tightly if that’s what you want; keep encouraging you and never give up; let you weep while acknowledging your pain

Second Stage of Labor: Resting Phase

  • Physical Changes: time from complete dilation to when begin to push; for up to 20 min, may have few noticeable contractions or have no urge to push; after baby’s head has slipped through cervix, uterus may need time to tighten around rest of baby’s body before you can begin to push
  • How you may feel/respond: feel relief, optimism, confidence and pain-free; have renewed energy, enthusiasm, hope even if you don’t experience a pause in contractions; no longer in the birth zone – your clearheaded, talkative and more aware of your surroundings
  • Ways To Cope: rest or doze, if you can; if want to push spontaneously, remind caregiver of preference, review positions, if resting phase lasts more than 20 min, change to upright positions to encourage an urge to push
  • Ways Partner/Doula Can Help: should match your enthusiasm, use the lull to renew energy (drink beverage, close eyes and rest for a moment, use restroom), help you change positions

Second Stage of Labor: Descent Phase

  • Physical Changes: baby rotates and descends into birth canal; oxytocin surges cause an urge to push, which may be mild at first, but becomes compelling an irresistible. You begin to push reflexively with contractions; contractions aren’t as close together as they were in transition, and they may be shorter; may last for a few min or up to 2 hours; at first, baby’s head can’t be seen then it appears at your vaginal opening when you push and retreats between pushes; your caregiver supports your perineum, applies warm compresses and may direct your pushing
  • How you may feel/respond: may feel inadequate in pushing until you get the hang of it; may find this phase reward, but you may find it painful and tedious. Either way, you’re working hard; may find the pressure in your vagina alarming and fear it will worsen, making you hold back from pushing; may feel less pain as baby’s head repositions
  • Ways To Cope: hold breath and strain when contractions make you feel that you can’t avoid pushing. You may bellow or cry out with effort; try to bulge your pelvic floor; consider touching baby’s head or watching her progress in mirror; if you’re holding back, or if pushing is painful, try to push into the pain and through it. Doing so will feel better than stopping when it hurts. Change your position every 30 min for comfort or to speed up labor progress. Consider directed or prolonged pushing if labor isn’t adequately progressing with spontaneous bearing down; if using directed pushing, follow directions for when and how long to hold your breath and strain
  • Ways Partner/Doula Can Help: encourage and praise your efforts (not yell push); apply cool, damp cloths to forehead, cheeks, neck and chest; report on progress (as soon as baby’s head is visible); remind you to release tension in perineum; remind caregiver of feelings about episiotomy if appropriate; support your position and help you change positions; if pushing is ineffective, remind you to open your eyes and look toward where your baby is emerging (may use a mirror)

Second Stage of Labor: Crowning and Birth

  • Physical Changes: baby’s head emerges; it no longer retracts into your vaginal opening between contractions; perineum and area around urethra are most vulnerable to tearing in this stage; caregiver either supports your perineum (warm compresses) or does episiotomy (unlikely)
  • How you may feel/respond: feel excited because your baby’s birth will be very soon; may feel a burning sensation from vaginal stretching; may have mixed feelings: may be tempted to push hard to get the birth over with or despite the burning. Or you may fear the burning feeling and become reluctant to push.
  • Ways To Cope: recognize the burning as a sign that labor is almost over. Use your partner’s help with positions. To slow the birth of your baby’s head and protect your perineum, stop pushing and pant/blow when your caregiver says; rejoice in baby’s birth!
  • Ways Partner/Doula Can Help: support you as you change positions; refrain from rushing you, help you keep from pushing as needed; say little or nothing when your caregiver is directing you to slow the birth of your baby’s head; rejoice in your baby’s birth!

Third Stage of Labor

  • Physical Changes: lasts up to 30 min; baby’s umbilical cord is clamped and cut; baby’s condition is evaluated using Apgar; if baby is fine and hospital policy allows, baby is placed on bare abdomen or chest; uterus contracts and shrinks, placenta separates from uterine wall. You expel placenta with a few pushes; may briefly tremble uncontrollable (normal); caregiver checks uterus to confirm it’s contraction and checks birth canal for tears
  • How you may feel/respond: feel relief that labor is over; become engrossed with baby; feel concern over trembling; feel alarm if contractions are still painful; feel surprise at discomfort when caregiver examines birth canal or massages your uterus after placenta is expelled
  • Ways To Cope: move away clothing so baby can be skin to skin; don’t rush breastfeeding – baby needs time to acclimate before she’s ready to feed. Let her show you that she’s ready to start suckling; ask for warm blanket to stop trembling; use light breathing and focus on partner or doula during uterine massage and examination or stitching of perineum; try to be patient during postpartum procedures. You’ll have time to focus on baby soon.
  • Ways Partner/Doula Can Help: help you get baby onto bare abdomen; help you breathe and focus through any painful procedures; get you a warm blanket if you’re trembling; open shirt and snuggle skin to skin with baby, if you can’t hold her right away; request that routine newborn procedures be delayed for at least an hour so you can bond with baby; enjoy the time with your new family!

(4) Systemic Medicines/Local and Regional Anesthetics

Systemic Medications – many forms: pills, injections, gases; all absorbed through bloodstream and affect entire body. Since carried in bloodstream, may affect baby as well because placenta cant screen them out. Magnitude of effects depends on type and amount of medication used and time between last dose and birth.   Other factors include baby’s maturity, health and response during labor.

Medication or byproducts might not disappear from baby’s bloodstream for hours or days, and neurobehavioral changes may be present during first few days after birth. Changes may be obvious or only noticeable to professions who use highly sensitive tests.

General anesthesia is systemic medication that causes total loss of sensation and consciousness. Used only for small % of cesarean. IV narcotics are systemic medications used most commonly in labor, although IM narcotics sometimes given.

IV Narcotic or Narcotic Like Medications – “takes edge off” reduce transmission of pain messages to pain receptors in brain.

  • Benefits: May work well if you want longer break between contractions so you can rest; may even be able to doze. Make take longer to notice a contraction has started, may fade away sooner but peak may still be intense.
  • Tradeoffs: IV fluids, EFM and restriction to bed may be necessary. May cause sleepiness or lethargy and may cause hazy feeling, disorientation or euphoria. Some women find it relaxation or pleasant while some feel out of control.
  • Possible Side Effects – itching, nausea, vomiting. May slow labor and cause variations in baby’s heart rate. Can take narcotic antagonist to reduce side effects, but it reduces pain relief. Narcotics in baby’s bloodstream may cause her to breathe slowly and have poor muscle tone. She can also receive antagonist.
  • Timing – effect or narcotics 60-90 min. Used in active labor when believed birth is at least 2 hours away. Timing allows effect on baby to fade before birth.
  • Local and Regional Anesthetics – often called blocks reduce feeling or numbness in particular area of body. When injected near specific nerves, it blocks transmission of sensations along them. Affects muscle control, blood flow and temperature in affected area. Most drug names end with suffix –caine such as lidocaine and bupivacaine.
  • Local Anesthetics (Perineal Block) – block sensation in small area near nerve endings. Injected into skin, mucous membranes or muscles. During labor, typically injected in perineum (perineal block). Can be injected in cervix (paracervical block) or vagina (pudendal block) but they aren’t often used.
  • Benefits: perineal block numbs perineum and is necessary for repair of episiotomy or lacerations. May numb perineum before episiotomy or forceps delivery.
  • Tradeoff: injections may be painful
  • Possible side effects: if perineal block given during repair of episiotomy or lacerations, side effects minimal. If given early in 2nd stage (rare), medication may affect baby’s heart rate during labor or his reflexes at birth
  • Timing – given during 2nd stage or episiotomy or forceps delivery is necessary. Given in 3rd stage for repair of episiotomy or lacerations.

Regional (Neuraxial) Analgesia and Anesthesia: Epidural and Spinal Blocks – neuraxial medications are injected in your lower back near nerve roots in spinal column. They affect the region of your body to which these nerves and their branches go. The region can be as small as your abdomen and lower back, or as large as the area from your chest to your toes. Medications are often a combination of of an anesthetic fentanyl, which enhances the overall numbing effect. A spinal block is an injection that takes effect quickly and lasts for an hour or two. An epidural catheter is a tube through which medication is given for as long as it’s needed.

  • Benefits – ACOG stated among all options for medicated pain relief, the epidural is the most effective for reducing pain, while allowing the woman to stay alert and actively participate in her labor. 98.8% have significant pain relief. Typically provides relief for rest of labor. Because of locations of injection sites, much smaller amounts of neuraxial can be used than needed for local or systemic analgesia. Fewer mental and respiratory side effects and higher level of satisfaction. Babies are more alert, breathe better and better muscle tone than babies born with higher doses of systemic narcotic like medications.
  • Tradeoffs – accompanied by IV fluids, bladder catheter, continuous monitoring of blood pressure, contractions and baby’s heart rate. Eating/drinking restriction and confined to bed. Reduces mobility. Feeling birth has become a medical event.
  • Possible side effects: most common include decreased blood pressure, longer labor, longer pushing stage and fever. Effects may lead to further interventions (Pitocin augmentation, vacuum extraction or forceps) and secondary side effects on both you and baby (uterine hyperstimulation or variations in baby’s heart rate). Itching/nausea. Some women worry about risk of paralysis or even death but this is so rare its nearly nonexistent. Experience won’t depend solely on skills of anesthesiologist; many factors including your and your baby’s physical state and well-being as well as how your body reacts to medications. Postpartum side effect may be shortened duration of breastfeeding. Woman is likely to stop breastfeeding sooner, partly because she might have taken longer after birth to begin holding and nursing her baby and partly because of a mistaken perception that she might not make enough milk. Problems can be overcome by early and frequent skin to skin and by starting breastfeeding within first hour. The earlier a woman initiates breastfeeding and the more often she nurses, the more milk she makes and the more likely she is to have breastfeeding success.
  • Timing – some caregivers require a woman be in active labor (4-5 cm dilated and strong, regular contractions). Epidurals given in early labor likely to slow or stall labor. Others give at any point in labor based on conflicting research that says it doesn’t prolong labor. Others give combined spinal-epidural (CSE), spinal narcotics early in labor and an epidural later on.

Procedure for Epidural and Spinal Blocks – as wait for anesthesiologist, contractions may be intense so may need to cope. Receive IV fluids to reduce risk of drop in blood pressure and to allow for administration of additional medications if needed. Procedures can take 10-20 min. if you have IV in already, nurse can increase flow to give you ¼ to 1 liter of fluid quickly. When anesthesiologist arrives, asked to lie curled on side or sit up and lean forward to curve back. Cleans lower back with antiseptic and numbs skin with local anesthetic. Prep can take 10 min or longer. May need support to help you sit or lie still during contractions. Where and how he places needed or catheter in back depends on type of block:

  • Spinal Block – inserted through dura (tough membrane that surrounds spinal cord) into the intrathecal space, which is filled with cerebrospinal fluid. Drugs given this way called intrathecal medications. Takes affect within minutes and lasts a few hours
  • Epidural catheter – inserted into epidural space, just outside dura. Thin plastic tube (Catheter) threaded through needle, needle is removed, catheter is taped to back, and test dose of medications is given through catheter to ensure you don’t react poorly to the drugs. Catheter is attached to a pump devise that steadily releases small amounts of anesthetic or analgesia. Within a few min, tingling and numbness are noticeable; within 15 min, likely to be completely numb from top of uterus to pelvis or even from chest to toes. Catheter remains in place and pain relief continues throughout labor. May receive doses by continuous drip, series of doses or from when you need them.
  • Combined spinalepidural (CSE)- epidural needle is inserted, then smaller spinal needle is inserted thought it and into intrathecal space for admin of spinal narcotic. Spinal needle is removed and epidural catheter is inserted. No medication is added to epidural at this time. Effects of spinal narcotic last a few hours or until cervix has dilated to 4-6 cm and intensifying contractions cause you to feel pain. When you need more relief, epidural medication is given through catheter.

Temp, blood pressure, pulse and blood oxygen levels are checked frequently.   May also have electrocardiogram (EKG). Many women receive excellent pain relief and don’t experience any side effects. If monitoring indicates that you or your baby are reacting poorly to neuraxial medications, then more interventions may be necessary.

If blood pressures drops significantly, baby’s heart rate will also decrease. Caregiver may turn you onto your side, place an oxygen mask on your face and ask you to breathe deeply. May be given medications or additional IV fluids to raise BP. Managing side effects often causes a cascade of interventions. If epidural causes contractions to slow down, may receive Pitocin to stimulate them – which may overstimulate your uterus, which can lead to variations in baby’s heart rate, which may increase need for cesarean.

Chances of fever increase since medication alters ability to regulate your temp. the longer it’s in place, the higher your risk. When you have a fever, baby’s heart rate may increase to a worrisome level and cesarean may be necessary. Epidural wont cause an infection in baby, but may increase chance shell be treated for one. If you have a fever during labor, baby may have one at birth but it can’t be assumed its because of epidural since it’s associated with infection so baby will be checked for infection with blood tests and possibly a spinal tap. She may be kept in special care nursery and given antibiotics for 2 days until test results are known. It will separate you from baby and can be worrisome.

Options for Epidurals:

  • Patient controlled epidural analgesia (PCEA) – allows you to press a button to give yourself more medication when you need it. Women tend to use less and are more satisfied than when dosage is controlled for them. Although you have some control, device has a timer that limits number of doses which are carefully measured so you cant overdose
  • Combined spinal-epidural (CSE) – uses spinal narcotic in early labor then an epidural in later labor, when you need more pain relief
  • Light or late epidural – reduce side effects by delaying epidural until in active labor and requesting low concentration
  • Policies vary among hospitals
    • Movement – ask whether you’re able to move and whether movement in bed is encouraged
    • Food and drink – some allow only ice chips but may be allowed clear fluids
    • Delayed pushing – may wait to push until baby’s head is visible at vaginal outlet. Has been proven to reduce vaginal tears, forceps delivery, vacuum extraction and need for cesarean.
    • Lowering dosage or discontinuing – by slowing/stopping at beginning of 2nd stage, may be able to bear down more effectively.

Note to Partners: stay with mom and relax together when she has an epidural. It may leave her feeling disconnected from her body and the birth experience; talk with her about the labor and your baby to help her reconnect with events. Help her change positions as much as possible; if she has a light epidural, she may be able to get on hands and knees.

Occasional challenges with epidurals – partner might not initially receive sufficient pain relief; she might experience windows of pain or pain might return after initial relief.

Might have discomforts such as itching, nausea and feeling overheated or chilled. Give her a massage, help her change positions, cover her with a warm blanket, place a cool cloth on her forehead or giver her ice chips or sips of water if allowed. Do not place heating pads or ice packs on any part of her body that’s affected by epidural.

Partner still may experience intense pressure or burning during pushing stage. Reassure her that these sensations are normal and signal that baby will be born soon. If holding one of her legs as she pushes, be careful not to pull back too far – think about her hips normal range of motion and don’t force beyond that point to avoid straining hips, thighs or lower back.

Help partner get lots of skin-to-skin contact with baby so breastfeeding can begin in first hour.

Failed Epidurals – 12% don’t provide complete pain relief when first inserted, while 7% may provide good pain relief initially but fade over time. Some only provide minimal pain relief, others allow for windows of pain. Staff may be able to fix it by changing your position, increasing medication or repositioning epidural catheter – these measures have resulted in good pain relief for nearly all women with epidurals (98.8%).

 

Possible Causes of Prolonged Active Labor- may sometimes be prevented or corrected by first using simple, low-cost interventions that carry little/no known risk. If not successful, intermediate interventions used and if necessary, more powerful and complex OB interventions with more risks used. Choice of intervention depends of apparent cause.

  • Fetal and fetopelvic factors – cephalopelvic disproportion (CPD – a poor fit between fetal head and maternal pelvis). CPD may involve a large head or malpositioned head, in which malposition (OP, OT or asynclitism) causes presentation of larger diameter (deflexed head) than when vertex presents in OA position. CPD may also occur with a discrepancy between shape of fetal head and dimensions and shape of maternal pelvis. Persistently high station in presence of adequate contractions may indicate poor fit of head, but not necessarily too large a head, within pelvis.

 

Chart 6.2 Diffuse pushing without progress

Ineffective or diffuse pushing with no progress after 20-30 min à change position (Try several) à effective pushing/improved progress and spontaneous vaginal birth OR à no improvement in 4-6 contractions à open eyes and look downward: “Self-directed pushing” à no improvement in 4-6 contractions à directed pushing à no improvement or fetal intolerance à operative delivery

If woman has an epidural– increase in length of 2nd stage and need for instrumental delivery.

Delayed pushing with an epidural

  • Normally, woman’s pelvic floor provides a resilient platform on which fetal head can rotate and muscles lining pelvis also provide resilient cushion that encourages rotation. Pressure on muscles elicits stretch response that plays important role in cardinal movements of descent (flexion, internal rotation, extension and external rotation). With epidural, pelvic floor muscles are anesthetized, resulting in reduction of muscle tone, which may inhibit rotation of fetal head. May explain increased need for instrumental deliveries. When combined with max breath holding and straining by woman from onset of 2nd stage, likelihood of difficult delivery due to persistent malposition or deep transverse arrest may be increased. Delayed pushing until head is visible at the introitus or until woman feels pressure or an urge to push decreases the instrumental delivery rate possibly by allowing more time for the fetus to gradually rotate and follow path of least resistance down birth canal. (Delayed pushing may provide little benefit if fetus is already in OA). With anesthesia, woman also lacks kinesthetic feedback to help her discover how to push effectively.
  • Anesthetized woman is restricted to few positions she can assume without full sensation or use of her legs.  Side lying, supine, semi-sitting, sitting upright, or in some cases of light anesthesia –squatting and hands ands knees. Changing position usually requires assistances. Likelihood of instrumental delivery 2x greater in women in sitting position
  • Anesthesia may interfere with usual spurt of endogenous oxytocin that is associated with pressure of presenting part within lower vagina. Normally, pressure on posterior vaginal wall or pelvic floor signals pituitary gland to release more oxytocin, resulting in stronger contractions, a greater urge to push, and more pressure on pelvic floor. Anesthesia blocks the oxytocin-producing feedback loop and progress if often impaired. Because of reduced urge to push associated with an epidural, pushing requires a greater voluntary effort than pushing in response to urge.

Evidence for epidural management:

  • Use of lower concentrations of anesthetic when epidural is first placed, possibly combining it with low-dose narcotics, or using a combined spinal-epidural (CSE) technique in hopes of allowing the woman more awareness and more motor control. Found no difference in mobility or OB or neonatal outcomes, including operative deliveries, maternal hypotension, maternal satisfaction or other outcomes. CSE was associated with more urinary retention and pruritis. Authors concluded review favored low-dose epidurals
  • Discontinuing or decreasing dose of epidural at end of 1st stage sometimes done, with purpose of improving pelvic floor muscle tone, encouraging rotation, and reducing need for instrumental delivery. Systematic review found insufficient evidence of benefit and inadequate pain relief.
  • Delayed pushing for up to 2 hrs, or until fetal head is OA or becomes visible at vaginal outlet (when labia are parted), may reduce need for forceps rotation without risk to newborn. Evidence indicates when pushing is delayed, thus avoiding forcing descent, the malpositioned fetus will often rotate and align well in pelvis, rather than becoming stuck in an unfavorable position
  • Removing time limit for 2nd stage w an epidural improves chances of spontaneous delivery without risk to neonate. Even if rotation and descent are slow, as long as fetus and woman are tolerating it well, many caregivers see no medical reason to intervene

Pushing effectively with epidural– often frustrating and ineffective, esp if woman unaware of urge to push. Caregivers urgent pleas for her to “push, push!” with count to 10 may make her feel she can’t do it right. One way to help woman push well and feel good about it is to use EF< as biofeedback device. Can instruct woman when to begin bearing down (when intensity rises about 30 mm Hg above baseline). He/she calls out numbers as contraction builds, then instructs her to bear down, and continues to call out number, which will increase rapidly with her bearing-down effort and should last 5-7 sec. partner tells her to breathe for the baby several times and to bear down again, repeating the numbers (Bear down – that’s it! 70, 73, 77, 94, 90 – go for 100! Great you did it! Now breathe for baby)

This emulates spontaneous bearing down, which results in better fetal oxygenation than prolonged and constant breath-holding and straining.

If progress is slow, changing positions every 20-30 min often improves progress.

 

Pharmacologic Interventions – Informed Consent – pregnant women have the right to be active participants in determining the best pain care approach to use during labor and birth. The primary health care provider and anesthesia care provider are responsible for fully informing women of the alternative methods of pharmacologic pain relief available in the birth setting. A description of the various anesthetic techniques and what they entail is essential to informed consent, even if the woman received information about analgesia and anesthesia earlier in her pregnancy. The initial discussion of pain management options ideally should take place in the 3rd trimester so the woman has time to consider alternatives. Nurses play a part in the informed consent by clarifying and describing procedures or by acting as the woman’s advocate and asking the primary health care provider for further explanations. 3 essential components of informed consent: procedure and its advantages/disadvantages must be thoroughly explained, woman must agree w plan of labor pain care as explained to her and her consent must be given freely w out coercion or manipulation from health care provider.

Legal Tip: Informed Consent for Anesthesia ~ woman receives in an understandable manner:

  • Explanation of alternative methods of anesthesia and analgesia available
  • Description of anesthetic, including its effects and the procedure for its administration
  • Description of the benefits, discomforts, risks and consequences for the mother, fetus and newborn
  • Explanation of how complications can be treated
  • Info that anesthetic is not always effective
  • Indication that woman may withdraw consent at any time
  • Opportunity to have any question answered
  • Opportunity to have components of consent explain in woman’s own words

Consent form will:

  • Be written or explain in woman’s primary language
  • Have woman’s’ signature
  • Have date of consent
  • Carry the signature of the anesthetic are provider, certifying that the woman has received and expresses understanding of the explanation

In some cultures, a husband is expected to consent to procedures performed on his wife. She may not be willing to do so unless husband also approves.

Nonpharmacologic Pain Management

  • Assess whether woman and partner have attended childbirth classes, their knowledge of labor process and current level of anxiety
  • Encourage support person to remain w woman in labor
  • Teach or review nonpharmacologic techniques available to decrease anxiety and pain during labor (focusing, relaxation, and breathing techniques, effleurage, and sacral pressure)
  • Explore other techniques that woman or significant other may have learned in childbirth classes (hypnosis, hydrotherapy, acupressure, biofeedback, therapeutic touch, aromatherapy, imaging, music)
  • Explore use of TENS if ordered by OB (to provide increased perception of control over pain and increase in release of endogenous opiates – endorphins)
  • Assist woman to change positions and use pillows – to reduce stiffness, aid circulation, promote comfort
  • Assess bladder for distention and encourage voiding often
  • Encourage rest between contractions
  • Keep woman and partner informed about progress
  • Guide couple through labor stages and phase, helping them use and modify comfort techniques appropriate to each phase
  • Support couple if pharmacologic measures are required to increase pain relief, explaining safety and effectiveness
  • Discuss woman’s birth plan and knowledge about birth process
  • Provide info about labor process
  • Inform woman about her labor status and fetus well being
  • Discuss rationales for all interventions
  • Incorporate nonpharmacologic interventions into plan of care
  • Provide emotional support and ongoing positive feedback

Timing of Administration – often nurse who notifies OB that woman is in need of relief from discomfort. Orders written as needed by woman and based on nurse’s clinical judgment. In past, pharmacologic measures were usually not implemented until labor had advanced to active phase of 1st stage and cervix had dilated to 4-5cm, to avoid suppressing the progress of labor. However, it is now known that epidural in early labor does not increase rate of cesarean birth. Whereas it may shorten the duration of 1st stage in some women, it lengthens it I on others. It is no longer recommended that women in labor reach a certain level of cervical dilation or fetal station before receiving it. It is still recommended that admin of systemic opioid analgesics be delayed until labor is well established.

Preparation for Procedures – woman benefits from knowing way medication is given, interval before medication takes effect and expected pain relief. Skin prep measures described and explanation for need to empty bladder before analgesic or anesthetic is administered and reason for keeping bladder empty. When an indwelling catheter is to be threaded into the epidural space, the woman should be told that she many have a momentary twinge down her leg, hip or back and this is not a sign of injury.

Administration of Medication – any medication can cause a minor or severe allergic reaction. As part of assessment for allergic reactions, nurse should monitor woman’s vital signs, respiratory effort, cardiovascular status, integument, and platelet and white blood cell count. Woman is observed for side effects of drug therapy, esp drowsiness and dyspnea. Minor reactions can consist of rash, rhinitis, fever, shortness of breath or pruritis. Management of less acute allergic response not an emergency.

Severe allergic reactions (anaphylaxis) may occur suddenly and lead to shock or death. Most dramatic form is sudden, severe broncospasm, upper airway obstruction and hypotension. Signs are largely caused by contraction of smooth muscles and may begin w irritability, extreme weakness, nausea and vomiting.   May lead to dyspnea, cyanosis, convulsions and cardiac arrest. Must be diagnosed and treated immediately. Initial treatment usually consists of placing woman in supine position, injecting epinephrine intramuscularly, administering fluid intravenously, supporting airway w ventilation if necessary and giving oxygen. If response inadequate, IV epinephrine should be given. Cardiopulmonary resuscitation may be necessary.

IV Route – preferred route of meds such as meperidine, fentanyl, butorphanol or nalbuphine is through IV tubing, administered into the port nearest the point of insertion of the infusion (proximal port). The medication is given slowly, in small doses, during a contraction. May be given over a period of 3-5 consecutive contractions if needed to complete the dose. Given during contractions to decrease fetal exposure to medication because uterine blood vessels are constricted during contractions and medication stays w in maternal vascular system for several seconds before uterine blood vessels reopen. IV infusion then restarted slowly to prevent a bolus of medication from being administered. With this method, amount of med crossing placenta to fetus is minimized. IV route has following advantages: onset of pain relief rapid and more predictable, pain relief is obtained w small doses of drug; duration more predictable.

IM Route – although analgesics still sometimes given IM< not preferred route for woman in labor. Advantages are quick administration and no need to start an IV line. Disadvantages include: onset of pain relief delayed; higher doses required; medication released at unpredictable rate from muscle tissue and is available for transfer across placenta to fetus.

Maternal medication levels unequal because of uneven distribution (maternal uptake) and metabolism. Those given in upper arm (deltoid muscle) seem to result in more rapid absorption and higher blood levels of medication that when administered in other sites. If regional anesthesia planned later in labor, deltoid muscle is preferred site. The autonomic blockade from regional anesthesia increases blood flow to gluteal region and accelerates absorption of medication that may be sequestered there. Admin of opioids subcutaneously in upper arm avoids this risk, and as a result is often used as an alternative to IM injection.

 

Effect of Cultural Diversity – final component of a complete psychosocial assessment is woman’s beliefs, values and practices. Cultural beliefs and traditions strongly influence the behaviors of the woman and her family during the postpartum period. Nurses are likely to come into contact w women from many different countries and cultures. All cultures have developed safe and satisfying methods of caring for new moms and babies. The nurse can identify some cultural beliefs and practices through observation and interaction w the mom and her family. Only by understanding and respecting the values and beliefs of each woman can the nurse design a plan of care to meet the individuals needs.

To identify cultural beliefs and practices when planning and implementing care, the nurse conducts a cultural assessment. Can be accomplished most easily through conversation w mom and partner. Some hospitals have assessment tools designed to identify cultural beliefs and practices that can influence care.   Components include ability to read and write English, primary language spoken, family involvement and support, dietary preferences, infant care, attachment religious or cultural beliefs, folk medicine practices, nonverbal communication and personal space preferences.

Postpartum care occurs within a sociocultural context. Rest, seclusion, dietary restraints, and ceremonies honoring mother are common traditional practices followed for promotion of health and well being of mom and baby. in some cultures, the postpartum period is considered a time of increased vulnerability for mom. To protect her there are restrictions on activity, diet, bathing and infant caretaking.

The postpartum period is seen by some cultures as a time for impurity for the mother. For as many days or weeks as she has lochial flow, she is considered impure and has limited contact w others. Sex prohibited during this time.

In many Asian cultures, the balance between yin and yang (cold and hot) is necessary for balance and harmony w the environment. Postpartum practices focus on helping mother achieve this balance. Pregnancy is considered a hot condition – it is believed that birth depletes mom’s body of heat through loss of blood and inner energy; this places her in a cold state for ~40 days until her womb is healed. The woman consumes only hot foods and beverages. Ex of hot foods include rice, eggs, beef and chicken soup. Seaweed soup is consumed by postpartum women for purpose of increasing milk production and helping to rid the body of lochia. Family members often bring in foods from home. T o help prevent the loss of heat from body, mom may be discouraged from showering or bathing for several days of weeks; however, there is attention to perineal care and hygiene. The temp of the hospital room is warmer than usual. Motherly likely spends most of time in bed to prevent cold air from entering the body and she has minimal contact w infant. Family members provide care for mom and newborn. For ex, in Korean culture, mother in law is charged w caring for daughter in law and newly born grandchild.

Women whose cultural beliefs involve balance between hot and cold prefer warm or hot beverages. Will not drink cold beverages or ice water. Likely to refuse routine application of cold packs or pads to perineum because conflicts w belief about preventing heat loss.

Hispanic and Latino women who have immigrated often observe period o f 40 days after birth as la cuarentena. Woman’s body is perceived to be open and vulnerable to drafts; la cuarentena is about closing the body (Liquid diet of nutritious drinks, soups and broths, binding abdomen, avoiding cool air, maintaining sexual abstinence). Activity is restricted and mother stay s at home. Common concern is evil eye or mal de ojo. They believe if someone admires/covets infant but does not touch him, it will cause bad luck, illness or even death. Some mothers place a bracelet with a black onyx hand, la manita de azabache on or near newborn.

Nurse needs to determine whether a woman is using complementary or alternative therapies (folk medicine) because active ingredients in some herbal preparations can have adverse physiologic effects when use in combination with prescribed medicines.

 

The Mother Lode of Pain: Getting It All Wrong in the Boston Globe: Dr. Sanghvi’s belief that choosing to feel pain in labor is “odd” when there is effective, safe and available pain relief. He says those who choose natural birth are attracting notice, setting up an artificial trial that precedes entry into a highly selective sorority.

Giving Birth with Confidence blog posted response.

Rather, pain early in labor lets women know they are in labor. Oxytocin levels rise, which make contractions stronger. Eventually, endorphins kick in and women go into a dream-like highly intuitive state. Without pain there is not the same kind of endorphin release. If have epidural or pain relief, oxytocin is not released in increasing amounts. There is a need for interventions, starting with Pitocin. Eliminating pain completely alters the course of labor and sets the stage for interventions and complications.

She compared labor to a long walk to the beach rather than a drive, stopping to feel all sensations on the way.

  1. e) Fear in birth

Stress Symptoms

Physical

  • Perspiration/sweaty hands
  • Increased heart rate
  • Trembling
  • Nervous tics
  • Dryness of throat and mouth
  • Tiring easily
  • Urinating frequently
  • Sleeping problems
  • Diarrhea, indigestion, vomiting
  • Butterflies in stomach
  • Headaches
  • Premenstrual tension
  • Pain in neck and lower back
  • Loss of appetite or overeating
  • Susceptibility to illness

Behavior

  • Stuttering and other speech difficulties
  • Crying for no apparent reason
  • Acting impulsively
  • Startling easily
  • Laughing in a high-pitched and nervous tone of voice
  • Grinding teeth
  • Increased smoking
  • Increased use of drugs and alcohol
  • Being accident-prone
  • Losing appetite or overeating

Psychologic

  • Feeling anxious
  • Feeling scared
  • Feeling irritable
  • Feeling moody
  • Low self-esteem
  • Fear of failure
  • Inability to concentrate
  • Embarrassed easily
  • Worrying about the future
  • Preoccupation w thoughts or tasks
  • Forgetfulness

 

Incidence and Etiology – placenta previa affects approx. 1/200 pregnancies at term. Some evidence suggests that the incidence of placenta previa is increasing, perhaps as a result of more cesarean births. In addition to a history of previous cesareans, other risk factors include advanced maternal age (>35-40), multiparty, history of prior suction curettage, and smoking. Living at higher altitude also risk factor. Like cig smoking, a higher altitude causes a decrease in uteroplacental oxygenation and thus a need for increased placental surface area. Also occurs more with male fetuses- possible explanation is placental sizes are larger. Multiple gestation also risk factor because of larger placental area. Women who had it in a previous pregnancy more likely to develop again, perhaps as a result of genetic predisposition. Previous cesarean results in endometrial damage and uterine scarring, which increases risk.

Clinical Manifestations – placenta previa typically characterized by painless bright red vaginal bleeding during 2nd or 3rd trimester. In past, was diagnoses after an episode of bleeding. Currently, most diagnoses by ultrasound before significant bleeding occurs. Bleeding is associated w stretching and thinning of lower uterine segment. Initial bleeding is usually a small amount and stops as clots form. Can recur at any time.

Vital signs may be normal, even w heavy blood loss, because a pregnant woman can lose up to 40% of her blood volume w out showing signs of shock. Clinical presentation and decreasing urinary output may be better indicators of acute blood loss than vital signs alone. FHR normal unless a major detachment of placenta occurs.

Abdominal exam usually reveals a soft, relaxed, nontender uterus w normal tone. Presenting part of fetus usually remains high because placenta occupies the lower uterine segment. Fundal height often greater than expected for gestational age. Because of abnormally located placenta, fetal malpresentation (Breech and transverse or oblique lie) is common.

Maternal and Fetal Outcomes – major maternal complication associated with placenta previa is hemorrhage. Another serious complication is development of an abnormal placental attachment (placenta accrete, increta or percreta). If excessive bleeding cannot be controlled, hysterectomy may be necessary. Because most women w placenta previa give birth by cesarean, surgery related trauma to structures adjacent to the uterus and anesthesia complications are also possible. In addition, blood transfusion reactions, anemia, therombophlebitis and infection may occur.

The greatest risk of fetal death is caused by preterm birth. Other fetal risks include stillbirth, malpresentation and fetal anemia. Intrauterine growth restriction (IUGR) has also been associated w placenta previa. This association can be related to poor placental exchange. The incidence of fetal anomalies is increased in pregnancies complicated by placenta previa.

Diagnosis – all women w painless vaginal bleeding after 20 weeks of gestation should be assumed to have a placenta previa until proven otherwise. A transabdominal ultrasound exam should be performed initially followed by a transvaginal scan, unless the transabdominal ultrasound clearly shows that the placenta is not located in the lower uterine segment. a transvaginal ultrasound is better than a trasnsabdominal scan for accurately determining placenta location. If ultrasonographic scanning reveals a normally implanted placenta, a speculum exam may be performed to rule out local causes of bleeding (Cervicitis, polyps, carcinoma of the cervix), and a coagulation profile is obtained to rule out other causes of bleeding.

Care Management – once placenta previa has been diagnosed, a management plan is developed. The woman will be managed either expectantly or actively, depending on gestational age, amount of bleeding and fetal condition.

Potential nursing diagnoses include:

  • Decreased cardiac output related to excessive blood loss secondary to placenta previa
  • Deficient fluid volume related to excessive blood loss secondary to placenta previa
  • Ineffective peripheral tissue perfusion related to hypovolemia and shunting of blood to central circulation
  • Anxiety related to maternal condition and pregnancy outcome
  • Grieving related to actual or perceived threat to self, pregnancy or infant

Expectant Management – (Observation and bed rest) is implemented if fetus is less than 36 weeks gestation and has normal FHR tracing, bleeding is milkd (<250 ml) and stops, and woman is not in labor. Purpose of expectant management is to allow the fetus time to mature. Woman will initially be hospitalized in a labor and birth unit for continuous FHR and contraction monitoring. Largebore IV access should be initiated immediately. Initial lab tests include hemoglobin, hematocrit, platelet count, and coagulation studies. A type and screen blood sample should be maintained at all times in the hospital’s transfusion services department to allow for immediate crossmatch of blood component therapy if necessary. If woman is at less than 34 weeks gestation, antenatal corticosteroids should be administered.

  1. f) Precipitous labor

Signs of Postoperative Complications After Discharge Following Cesarean: temp exceeding 100.4F, painful urination, urgency, cloudy urine; heavier than normal menstrual period, clots, odor; cesarean incision w redness, swelling, bruising, foul smelling discharge or bleeding, wound separation; severe, increasing abdominal pain

Trial of Labor – observance of a woman and her fetus for a reasonable period (4-6 hrs) of spontaneous active labor to assess safety of vaginal birth for mother and infant. May be initiated if mother’s pelvis is of questionable size or shape or if fetus is in abnormal presentation or position. By far the most common reason for a TOL is if the woman wishes to have a vaginal birth after a previous cesarean. A woman w a previous cesarean w a low transverse uterine incision may be a candidate. Fetal sonography, maternal pelvimetry, or both may be done before a TOL to rule out CPD. During a TOL the woman is evaluated for active labor, including adequate contractions, engagement and descent of the presenting part, and effacement and dilation of the cervix.

Nurse assesses maternal vital signs and FHR pattern and is alert for signs of potential complications. If complications develop, the nurse is responsible for initiating appropriate actions, including notifying the primary health care provider, and for evaluating and documenting the maternal and fetal responses to interventions. Nurses must recognize that the woman and her partner are often anxious about maternal and fetal well-being. Supporting and encouraging the woman and her partner and providing info regarding progress can reduce stress and enhance the labor process and facilitate a successful outcome.

Vaginal Birth After Cesarean – indications for primary cesarean birth, such as dysfunctional labor, breech presentation or abnormal FHR or patterns, often are nonrecurring. Therefore, a woman who has had a cesarean w a low transverse incision may subsequently become pregnant, experience no contraindications to labor and vaginal birth during the pregnancy and choose to attempt a VBAC.

The overall success rate of VBAC is approx. 60-80%. Strongest predictors for successful VBAC are a prior vaginal birth and spontaneous (Rather than induced/augmented labor). Women whose first cesarean birth was performed because of a nonrecurring indication (Breech) also likely to have successful VBAC.   Women w following characteristics are less likely to have a successful VBAC:

  • Recurrent indication (labor dystocia) for initial cesarean
  • Increased maternal age
  • Non-Caucasian race or ethnicity
  • Gestational age >40 weeks
  • Maternal obesity (BMI >30)
  • Preeclampsia
  • Short interpregnancy interval
  • Estimated fetal weight >4000 g
  • Giving birth at a rural or private hospital

Women who success w VBAC and avoid major abdominal surgery have less hemorrhage, fewer infections and a shorter recovery period than women who give birth by repeat cesarean. Major risk associated w VBAC is uterine rupture. Other maternal risks include operative injury, blood transfusion, hysterectomy, endometritis, and death.

Women most often the primary decision makers with regard to choice of birth method. During prenatal period, the woman should be given info about VBAC and encouraged to choose it as an alternative to repeat cesarean, as long as no contraindications exist. VBAC Support groups (www.vbac.com) and prenatal classes can help prepare woman psychologically for labor and vaginal birth. Women need to believe not only that their efforts during a TOL will be successful but also that they are fully capable of doing what is necessary to give birth vaginally. They must be given the opportunity to discuss their previous labor experience, including feelings of failure and loss of control, and to express concern they may have about how they will manage during their upcoming labor and birth. Not everyone is enthusiastic about TOL and VBAC. After being fully informed about benefits and risks, more than 25% of potential candidates choose to have a repeat cesarean instead.

If woman chooses TOL, nurse is attentive to her psychologic as well as physical needs. Anxiety increases the release of catecholamines and can inhibit the release of oxytocin, thus delaying the progress of labor and possible leading to a repeat cesarean. To alleviate such anxiety, the nurse can encourage the woman to use breathing and relaxation techniques and to change positions to promote labor progress. The woman’s partner can be encouraged to provide comfort measures and emotional support. Collaboration among the woman in labor, her partner, the nurse and other health care providers often results in a successful VBAC. If a TOL does not result in vaginal birth, the woman will need support and encouragement to express her feelings about having another cesarean. It is very important that this outcome not be labeled as a failed VBAC.

Since 1996, VBAC rates have been decreasing w current rate less than 10%. Both medical and nonmedical factors have contributed to this decline. Experts affirmed that TOL is a reasonable option for many women who have had previous cesarean. They found that many women appropriate candidates do not have access to providers and health care facilities able and willing to offer the option. ACOG continues to recommend that TOL and VBAC be offered only in facilities that have staff immediately available to provider emergency care. Because resources for immediate cesarean may not be available in all birthing facilities, best alternative in some situations may be to refer interested women to other facilities that have obstetric, anesthetic, pediatric, and surgical staff necessary to offer TOL and VBAC.

Selection Criteria for VBAC

  • 1 or 2 previous low-transverse cesarean births
  • Clinically adequate pelvis
  • No other uterine scars of history of previous rupture
  • Physicians immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean if necessary

 

Rapid Unattended Birth – some women’s labors begin with contractions less than 4 min apart and progress rapidly. If so, head for birthplace immediately or call midwife. Do not drive yourself. If can see baby’s head at vaginal opening or feel him coming down birth canal, stay at home – don’t travel; its better to have shelter and essential supplies. Have driver pull over to side of road and help you deliver baby.

Quick Checklist for Rapid Unattended Birth

  • Get help, if possible. Even a child can assist you
  • Gather clean sheets, towels, paper towels, tissues and extra clothing
  • Wash hands
  • Remove all clothing from bottom/vaginal area
  • Lie on side or sit leaning back – make sure in clean place with enough room for baby to rest as she slips out
  • Put sheet, towel or some clothing under bottom
  • Try not to hold breath if body is pushing. Pant through each contraction until baby is born
  • After baby is born, wipe away any mucus from nose/mouth. Remove any membranes covering her face. Wipe her head and body to dry her. Place her on your bare abdomen or chest to keep her warm. Cover with cloth, towels, clothing
  • Don’t cut cord!
  • Put baby to breast and let her breastfeed
  • If at home, await birth of placenta (if hasn’t expelled in 15-20 min, try kneeling to see if gravity can help it come out. If unsuccessful, go to hospital)
  • Place placenta in nearby bowl, newspaper or cloth
  • Place towels or pad between legs to absorb blood flow
  • Go to hospital or get medical help a.s.a.p. to check both you and baby. Medical professional will cut cord.

Possible Problems after a rapid unattended birth – usually both mother and baby are fine, but complications may develop. Medical help is likely only minutes away.

  • If baby doesn’t breathe spontaneously – have someone call 911 if possible. Place baby on stomach with his head lower than his trunk, then rub his back briskly but gently. If he doesn’t respond within 30 sec, hold his ankles together and smack the soles of his feet sharply. If still doesn’t breathe, check for mucus in mouth with finger. If know how to give infant CPR, do so. If you don’t, call 911 for help.
  • If you have excessive bleeding from vagina – more than 500 milliliters or 2 cups may indicate postpartum hemorrhage, esp if you begin to have symptoms of shock such as rapid pulse, pale skin, trembling, faintness, feeling cold and sweating. Firmly massage fundus (top of uterus (in a circle until uterus contracts and encourage baby to nurse (or you or partner can stroke nipples to stimulate release of oxytocin)) to stimulate contractions. To avoid shock, like down and elevate hips so they’re higher than head.
  1. g) Prolapsed cord

Prolapsed Cord – during normal vaginal birth, umbilical cord stays high in uterus as baby descends through birth canal and out the vaginal opening. With prolapsed cord, cord slips below baby so it’s either in vagina or lying between baby and cervix. Although rare (1/400), its potentially serious because baby’s body can compress cord, especially during contractions and reduce amount of oxygen available to her.

Can occur when membranes rupture with a gush of amniotic fluid and cord is allowed to slip toward vaginal opening because baby’s body doesn’t block its passage. Can happen if baby is premature or in a breech or transverse presentation or if her head isn’t yet engaged in pelvis and is still “floating high”. If pregnant with multiples, risk of prematurity and malposition increases, which increase risk of prolapsed cord.

At prenatal visits in late pregnancy, ask caregiver to check baby’s position via ultrasound or hand. If membranes rupture with gush and you know baby is breech or transverse, take following steps:

  • Get into open knee chest position so gravity can help move baby away from cervix and possibly off cord.   Might or might not be able to feel cord in vagina
  • Arrange for immediate transportation to hospital
  • Remain in knee chest position in vehicle/ambulance
  • When arrive, tell staff you may have prolapsed cord. Nurse will insert hand into vagina to keep baby off cord. Expect cesarean a.s.a.p.

if baby’s head is still unengaged but low in pelvis, can follow caregivers advice for managing rupture membranes. If you don’t know whether baby’s head is low or high, risk of prolapsed cord is less if position is unknown than if head is known to be high. May take above steps as precaution.

  1. Laboring with medications
  2. a) Risks and benefits

 

Preparing to Labor with Pain Medications

Learn about pain medications during pregnancy whether or not you plan to use them. That way, if need arises, you have knowledge about them and can make an informed decision. Both you and baby are affected if you take pain medications so know all possible risks and benefits.

Weighing Risks/Benefits of Pain Medications – benefits include increased ability to relax and sleep, reduction or elimination of pain. Side effects are often mild, manageable and familiar to hospital staff. All interventions have potential risks – decreased blood pressure in mom, prolonged labor, forceps delivery or vacuum extraction, fever in mom or baby and variations in baby’s heart rate. While risks are moderate, may require additional interventions that have their own potential side effects.

  • While medications can minimize or eliminate pain, they generally can’t prevent you from experiencing any.
  • Any medication you receive affects baby. since baby’s liver and kidneys are immature, effects of some drugs last longer than for you. Medication effect depends on drug, amount received, how and when it’s given and other factors. PCNGuide
  • Pain medications affect labor progress. They slow contractions and may increase need for other medical interventions. If labor progress is abnormally slow, drugs may speed up progress by letting you relax
  • Some require restrictions: to bed, of eating and drinking, IV fluids, Pitocin augmentation, administration of oxygen, frequent monitoring of blood pressure and blood oxygen levels, bladder catheterization, EFM, vacuum extraction and cesarean.
  1. b) Key vocabulary

Key Vocabulary of Pain Medications

  • Route of administration – oral is a pill or liquid you swallow; inhalation is a gas you breathe; intramuscular is a shot given into muscle; intravenous is an injection into a vein – often through IV catheter; neuraxial are drugs injected into space surrounding spinal cord such as epidurals and spinal blocks. How quickly it takes effect depends on route
  • Areas of effect – systemic (Affecting entire body), regional (large area) or local (specific, relatively small part of body). Need more medication to get desired results with systemic than regional or local
  • Type of effect – analgesia reduces perception of pain while anesthesia indicates loss of sensation including pain sensation; anesthetics block nerve endings from sending pain impulses to brain
  1. c) System medications

Systemic Medications

Pills, injections, gases. They are carried in bloodstream and may affect baby as well because placenta can’t screen them out. Magnitude depends on type and amount used and time between last dose and birth. Other factors include baby’s maturity, health and response during labor.

  • Medication or its byproducts might not disappear from baby’s bloodstream for hours or days and neurobehavioral changes may be present during first few days. Changes may be obvious or only noticeable to professionals who use highly sensitive tests.
  • General anesthesia is systemic medication that causes total loss of sensation and consciousness. Its used only for a small % of cesarean births. IV narcotics are systemic medications used most commonly in labor, although IM narcotics are sometimes given.
  1. d) IV Narcotics and narcotic-like medications

IV Narcotics or Narcotic-like Medications – reduce transmission of pain messages to pain receptors in brain.

  • Benefits – takes the edge off pain. May take you longer to notice a contraction has started and may seem to fade away sooner. Peak may still be intense enough to feel pain. May work well if you can handle peak but want to have longer break between contractions so you can rest; may even be able to doze between contractions and wake up to manage peak.
  • Tradeoffs – IV fluids, EFM and restriction to bed. May cause sleepiness or lethargy and may cause hazy feeling, disorientation or euphoria. Some find feeling relaxing/pleasant while others feel out on control.
  • Possible side effects – itching, nausea, vomiting. May slow labor and cause variations in baby’s heart rate. Can receive narcotic antagonist to reduce side effects, but it’ll reduce pain relief. After birth, narcotics in baby’s bloodstream may cause her to breathe slowly and have poor muscle tone. She can receive a narcotic antagonist if needed.
  • Timing – effects last 60-90 min. used in early labor when its believed birth is at least 2 hours away. Timing allows effects on baby to fade before birth.
  1. e) Local and regional anesthetics

Local and Regional Anesthetics – often called blocks reduce feeling or numbness in particular area of body. When injected near specific nerves, it blocks transmission of sensations along them. Affects muscle control, blood flow and temperature in affected area. Most drug names end with suffix –caine such as lidocaine and bupivacaine.

Local Anesthetics (Perineal Block) – block sensation in small area near nerve endings. Injected into skin, mucous membranes or muscles. During labor, typically injected in perineum (perineal block). Can be injected in cervix (paracervical block) or vagina (pudendal block) but they aren’t often used.

  • Benefits: perineal block numbs perineum and is necessary for repair of episiotomy or lacerations. May numb perineum before episiotomy or forceps delivery.
  • Tradeoff: injections may be painful
  • Possible side effects: if perineal block given during repair of episiotomy or lacerations, side effects minimal. If given early in 2nd stage (rare), medication may affect baby’s heart rate during labor or his reflexes at birth
  • Timing – given during 2nd stage or episiotomy or forceps delivery is necessary. Given in 3rd stage for repair of episiotomy or lacerations.

Regional (Neuraxial) Analgesia and Anesthesia: Epidural and Spinal Blocks – neuraxial medications are injected in your lower back near nerve roots in spinal column. They affect the region of your body to which these nerves and their branches go. The region can be as small as your abdomen and lower back, or as large as the area from your chest to your toes. Medications are often a combination of of an anesthetic fentanyl, which enhances the overall numbing effect. A spinal block is an injection that takes effect quickly and lasts for an hour or two. An epidural catheter is a tube through which medication is given for as long as it’s needed.

  • Benefits – ACOG stated among all options for medicated pain relief, the epidural is the most effective for reducing pain, while allowing the woman to stay alert and actively participate in her labor. 98.8% have significant pain relief. Typically provides relief for rest of labor. Because of locations of injection sites, much smaller amounts of neuraxial can be used than needed for local or systemic analgesia. Fewer mental and respiratory side effects and higher level of satisfaction. Babies are more alert, breathe better and better muscle tone than babies born with higher doses of systemic narcotic like medications.
  • Tradeoffs – accompanied by IV fluids, bladder catheter, continuous monitoring of blood pressure, contractions and baby’s heart rate. Eating/drinking restriction and confined to bed. Reduces mobility. Feeling birth has become a medical event.
  • Possible side effects: most common include decreased blood pressure, longer labor, longer pushing stage and fever. Effects may lead to further interventions (Pitocin augmentation, vacuum extraction or forceps) and secondary side effects on both you and baby (uterine hyperstimulation or variations in baby’s heart rate). Itching/nausea. Some women worry about risk of paralysis or even death but this is so rare its nearly nonexistent. Experience wont depend solely on skills of anesthesiologist; many factors including your and your baby’s physical state and well-being as well as how your body reacts to medications. Postpartum side effect may be shortened duration of breastfeeding. Woman is likely to stop breastfeeding sooner, partly because she might have taken longer after birth to begin holding and nursing her baby and partly because of a mistaken perception that she might not make enough milk. Problems can be overcome by early and frequent skin to skin and by starting breastfeeding within first hour. The earlier a woman initiates breastfeeding and the more often she nurses, the more milk she makes and the more likely she is to have breastfeeding success.
  • Timing – some caregivers require a woman be in active labor (4-5 cm dilated and strong, regular contractions). Epidurals given in early labor likely to slow or stall labor. Others give at any point in labor based on conflicting research that says it doesn’t prolong labor. Others give combined spinal-epidural (CSE), spinal narcotics early in labor and an epidural later on.

Procedure for Epidural and Spinal Blocks – as wait for anesthesiologist, contractions may be intense so may need to cope. Receive IV fluids to reduce risk of drop in blood pressure and to allow for administration of additional medications if needed. Procedures can take 10-20 min. if you have IV in already, nurse can increase flow to give you ¼ to 1 liter of fluid quickly. When anesthesiologist arrives, asked to lie curled on side or sit up and lean forward to curve back. Cleans lower back with antiseptic and numbs skin with local anesthetic. Prep can take 10 min or longer. May need support to help you sit or lie still during contractions. Where and how he places needed or catheter in back depends on type of block:

  • Spinal Block – inserted through dura (tough membrane that surrounds spinal cord) into the intrathecal space, which is filled with cerebrospinal fluid. Drugs given this way called intrathecal medications. Takes affect within minutes and lasts a few hours
  • Epidural catheter – inserted into epidural space, just outside dura. Thin plastic tube (Catheter) threaded through needle, needle is removed, catheter is taped to back, and test dose of medications is given through catheter to ensure you don’t react poorly to the drugs. Catheter is attached to a pump devise that steadily releases small amounts of anesthetic or analgesia. Within a few min, tingling and numbness are noticeable; within 15 min, likely to be completely numb from top of uterus to pelvis or even from chest to toes. Catheter remains in place and pain relief continues throughout labor. May receive doses by continuous drip, series of doses or from when you need them.
  • Combined spinalepidural (CSE)- epidural needle is inserted, then smaller spinal needle is inserted thought it and into intrathecal space for admin of spinal narcotic. Spinal needle is removed and epidural catheter is inserted. No medication is added to epidural at this time. Effects of spinal narcotic last a few hours or until cervix has dilated to 4-6 cm and intensifying contractions cause you to feel pain. When you need more relief, epidural medication is given through catheter.

Temp, blood pressure, pulse and blood oxygen levels are checked frequently.   May also have electrocardiogram (EKG). Many women receive excellent pain relief and don’t experience any side effects. If monitoring indicates that you or your baby are reacting poorly to neuraxial medications, then more interventions may be necessary.

If blood pressures drops significantly, baby’s heart rate will also decrease. Caregiver may turn you onto your side, place an oxygen mask on your face and ask you to breathe deeply. May be given medications or additional IV fluids to raise BP. Managing side effects often causes a cascade of interventions. If epidural causes contractions to slow down, may receive Pitocin to stimulate them – which may overstimulate your uterus, which can lead to variations in baby’s heart rate, which may increase need for cesarean.

Chances of fever increase since medication alters ability to regulate your temp. the longer it’s in place, the higher your risk. When you have a fever, baby’s heart rate may increase to a worrisome level and cesarean may be necessary. Epidural wont cause an infection in baby, but may increase chance shell be treated for one. If you have a fever during labor, baby may have one at birth but it can’t be assumed its because of epidural since it’s associated with infection so baby will be checked for infection with blood tests and possibly a spinal tap. She may be kept in special care nursery and given antibiotics for 2 days until test results are known. It will separate you from baby and can be worrisome.

  1. f) Epidurals

Options for Epidurals:

  • Patient controlled epidural analgesia (PCEA) – allows you to press a button to give yourself more medication when you need it. Women tend to use less and are more satisfied than when dosage is controlled for them. Although you have some control, device has a timer that limits number of doses which are carefully measured so you cant overdose
  • Combined spinal-epidural (CSE) – uses spinal narcotic in early labor then an epidural in later labor, when you need more pain relief
  • Light or late epidural – reduce side effects by delaying epidural until in active labor and requesting low concentration
  • Policies vary among hospitals
    • Movement – ask whether you’re able to move and whether movement in bed is encouraged
    • Food and drink – some allow only ice chips but may be allowed clear fluids
    • Delayed pushing – may wait to push until baby’s head is visible at vaginal outlet. Has been proven to reduce vaginal tears, forceps delivery, vacuum extraction and need for cesarean.
    • Lowering dosage or discontinuing – by slowing/stopping at beginning of 2nd stage, may be able to bear down more effectively.
  1. g) Comfort and support with medications

Note to Partners: stay with mom and relax together when she has an epidural. It may leave her feeling disconnected from her body and the birth experience; talk with her about the labor and your baby to help her reconnect with events. Help her change positions as much as possible; if she has a light epidural, she may be able to get on hands and knees.

Occasional challenges with epidurals – partner might not initially receive sufficient pain relief; she might experience windows of pain or pain might return after initial relief.

Might have discomforts such as itching, nausea and feeling overheated or chilled. Give her a massage, help her change positions, cover her with a warm blanket, place a cool cloth on her forehead or giver her ice chips or sips of water if allowed. Do not place heating pads or ice packs on any part of her body that’s affected by epidural.

Partner still may experience intense pressure or burning during pushing stage. Reassure her that these sensations are normal and signal that baby will be born soon. If holding one of her legs as she pushes, be careful not to pull back too far – think about her hips normal range of motion and don’t force beyond that point to avoid straining hips, thighs or lower back.

Help partner get lots of skin-to-skin contact with baby so breastfeeding can begin in first hour.

Failed Epidurals – 12% don’t provide complete pain relief when first inserted, while 7% may provide good pain relief initially but fade over time. Some only provide minimal pain relief, others allow for windows of pain. Staff may be able to fix it by changing your position, increasing medication or repositioning epidural catheter – these measures have resulted in good pain relief for nearly all women with epidurals (98.8%).

Key Points – no one should suffer in labor; see PCNGuide for pain medications

  1. Second stage of labor
  2. Non-medical ways to encourage second stage labor

Prolonged 2nd Stage of Labor: 2nd stage begins when cervix is fully dilated and ends with birth of baby. Labor may slow or stop for reasons that can cause a prolonged active phase (such as exhaustion or a malpositioned baby). Sometimes, receiving an epidural prolongs the 2nd stage.

One problem unique to 2nd stage is baby that doesn’t descend through birth canal, despite hours of pushing by her mother (. In rare circumstances, it’s difficult to resolve – if baby can fit through upper part of pelvis (pelvic inlet) but can’t rotate and descend through lower part (pelvic outlet). 2nd rare problem is short umbilical cord, which can cause baby’s heart rate to slow during contractions or limit her descent because cord can’t stretch enough for her passage through vaginal opening. Sometimes, a cord of sufficient length can pose same problem if its wrapped around baby; in most cases cord remains loose enough to prevent a problem. In both examples, cesarean may be required.

Shoulder dystocia is a rare but potentially serious complication that occurs when baby’s head has been born but birth of her shoulders is delayed because they’re too broad to fit through pelvis. It becomes critical for baby to finish being born quickly because oxygen supply from cord may be reduced. Caregiver may use skilled maneuvers to rotate baby and deliver shoulders. Often episiotomy is necessary and sometimes baby’s collarbone breaks in effort to get her out quickly. Newborns collarbone is flexible and usually heals quickly.

What You Can Do If 2nd Stage is Prolonged: Change positions – squatting, lap squatting, supported squat or dangle. They use gravity and allow for maximum enlargement of the pelvic outlet. Standing, semi sitting and hands and knees. If unable to use because epidural limits movements, try exaggerated lithotomy position flat on back with knees drawn up toward shoulders – may help baby move beneath pubic bone. If tension in perineum seems to interfere with ability to bear down, try sitting on toiled. Caregiver may suggest prolonged pushing.

 

Posterior Position in 2nd stage – link between persistent posterior position and range of maternal outcomes including prolonged 1st and 2nd stage labor, oxytocin augmentation, epidural, assisted vag birth, sphincter tears, cesareans and postpartum hemorrhage.

  • Evidence base of 9 prevailing concepts that guide current labor management for posterior position concluded that only 2 proven: ultrasound diagnosis to identify fetal position and digital or manual rotation in 2nd stage to correct malposition. In terms of birth outcome, it is the position of the baby at commencement of 2nd stage that is best predictor of outcome. Back pain is unreliable marker of OP position as it can occur in OA labors and not occur in OP ones. A delay in labor without back pain could still be related to an OP position. Vaginal examinations were found to be unreliable in diagnosing OP. Some evidence that changes of position may help OP position to rotate and certainly many midwives advocate lunge maneuver (creating disequilibrium in hips by stepping up and down) as well as pelvic squeeze (pressing inwards on iliac crests). Trent towards OA rotation in OP labors as well asa successful treatment of backache with h ands/knees position. Good section on OP in Holistic Midwifery Volume II.
  • Tips for delay in 2nd stage: these are experiential, based on general good practice principles, anecdotal or sometimes counter-intuitive; little research on physiological interventions for this scenario:
  • Variety of upright postures
  • Psychological barriers
  • Empty bowel/bladder
  • Offer water immersion
  • Suggest nipple/clitoral stimulation
  • Change of voice tone or carer, if possible
  • Recumbent postures, including McRoberts
  • Coached pushing but for short time frames
  • Agree a time frame before initiating an assisted vaginal birth or transfer out of home or birth centers – sometimes mentioning the end point of forceps or transfer to labor ward seems to bring a reward

Attitudes and philosophy – resist temptation after experience above to always do a confirmatory vaginal examination when signs of 2nd stage appear, takes experience and a supportive environment

Attitudinal change to enhance woman’s autonomy is imperative; a move from:

  • Loss of autonomy to being in control
  • Passive to active
  • Dependence to independence

For midwives, movement from:

  • Control to facilitation
  • Dominance to masterly inactivity
  • Surveillance and monitoring to watchful expectancy
  • More to less

 

Signs Preceding Labor – in 1st time pregnancies, uterus sinks downward and forward ~ 2 weeks before term, when fetus’s presenting part (usually fetal head) descends into true pelvis – aka “lightening” or “Dropping”. Happens gradually. Feel less pressure below ribcage and breathe more easily afterwards but more bladder pressure. Return of urinary frequency occurs. In multiparous woman, lightening may not take place until after uterine contractions are established and true labor is in progress.

Woman may complain of persistent low backache and sacroiliac distress as a result of relaxation of pelvic joints. Braxton Hick contractions.

Vaginal mucus becomes more profuse in response to extreme congestion of vaginal mucous membranes. Brownish or blood-tinged cervical mucus (bloody show) may be passed. Cervix becomes soft (ripens), and partially effaced and may begin to dilate. Membranes may rupture spontaneously.

Common in days preceding labor: weight loss of 1-3.5 lbs, caused by water loss resulting from electrolyte shifts that in turn are produced by changes in estrogen and progesterone levels and surge of energy. Burst of energy to clean house, put everything in order. Less commonly: diarrhea, nausea, vomiting, indigestion.

 

Signs Preceding Labor

  • Lightening
  • Return of urinary frequency
  • Backache
  • Stronger Braxton Hicks contractions
  • Weight loss of 1-3.5 lbs
  • Surge of energy
  • Increased vaginal discharge, bloody show
  • Cervical ripening
  • Possible rupture of membranes

Onset of Labor – cannot be ascribed to single cause. Many factors – changes in maternal uterus, cervix and pituitary gland. Hormones produced by normal fetal hypothalamus, pituitary and adrenal cortex probably contribute. Progressive uterine distention, increasing intrauterine pressure and gaining of placenta seem to be associated with increasing myometrial irritability. This is a result of increased concentrations of estrogen and prostaglandins, as well as decreasing progesterone levels. Effects of these result in strong, regular, rhythmic uterine contractions.

Stages of Labor – in women w out complications and vertex presentation 1) regular progression of uterine contractions 2) effacement and progressive dilation of cervix 3) progress in descent of presenting part.

  • 1st stage of labor – onset of regular contractions to full effacement and dilation of cervix. Much longer than 2nd and 3rd stages combined. Great variability is the rule. Traditionally divided into 3 phases: latent, active and transition phase. Women w epidural may not notice transition phase. During latent phase, there is more progress in effacement of cervix and little increase in descent. Active and transition phases – more rapid dilation of cervix and increased rate of descent of presenting part.
  • 2nd stage of labor – cervix fully dilated to birth of fetus. Composed of 2 phases: latent (passive fetal descent) and active pushing. Latent phase – fetus continues to descent and rotate to OA. Urge to bear down not strong and some women do not experience. Active pushing – strong urges to bear down ad presenting part descents and presses on stretch receptors of pelvic floor.
  • 3rd stage – birth of fetus until placenta delivered. Placenta normally separates with 3rd or 4th strong contraction after infant born. After separated, can be delivered with next contraction.
  • 4th stage – delivery of placenta and 2 hrs post birth. Recover physically; observe for complications such as abnormal bleeding.

Mechanism of Labor – Turns and other adjustments necessary in human birth. Female pelvis has varied contours and diameters at different levels. 2 cardinal movements that occur in vertex presentation: engagement, descent, flexion, internal rotation, extension, external rotation (restitution) and birth by expulsion. Combination of movements occur simultaneously. Engagement involves both descent and flexion.

Fig 16-12 Cardinal movements of mechanism of labor. LOA. Pelvis figures show position of fetal head as seen by birth attendant. Engagement, and descent. Flexion. Internal rotation to OA. Extension. External rotation beginning (restitution). External rotation.

Engagement– when biparietal diameter of head passes pelvic inlet, head is said to be engaged. In most nulliparous women, occurs before onset of active labor because firmer abdominal muscles direct presenting part into pelvis. In multiparous women, because abdominal musculature is more relaxed, head often remains freely movable above pelvic brim until labor is established.

  1. Medical care for prolonged second stage labor

Medical care for prolonged second stage labor

Vacuum extraction, forceps delivery, episiotomy or cesarean if attempts to change position aren’t helpful. Caregiver may also recommend if you’re exhausted and unable to push effectively, if you’ve received medications that inhibit your efforts and slow your labor, if Pitocin augmentation isn’t helping or if baby isn’t tolerating labor. See PCNGuide

  • Episiotomy – surgical incision of perineum that enlarges vaginal outlet. Performed before baby’s head is born as perineum is stretching. Has been found to short time to birth by 5-15 min, which may be necessary if baby is in distress. May recommend if using forceps to deliver or if shoulder dystocia suspected. After birth, repaired with sutures and mom may have moderate to severe pain during first few days.
    • Routine Episiotomy – studies in 90s found no benefit and some risks to this. Caregivers who continue (some have rates as high as 80%) hold on to 2 outdated beliefs: spontaneous tear is worse and that stretched perineum is more damaged. Most spontaneous tears (half of vaginal births) are smaller than average episiotomy and serious large tears are more likely to occur with one. If baby is in distress in late 2nd stage, it may be necessary.
  • Vacuum Extraction and Forceps Delivery – silicone suction cup vs long steel tongs. Vacuum used more often. Both used more often on those with epidurals. Caregiver pulls on it as woman pushes during contractions.   Both instruments are generally safe although bruising; swelling and scraping of baby’s head often occur. Caregiver discontinues use if its obviously baby isn’t descending. At that point, cesarean becomes necessary.
  1. Episiotomy

Birth in Delivery Room or Birthing Room – stirrups not same height will strain ligaments in woman’s back as she bears down, leading to considerable discomfort in postpartum period.

Once woman is positioned, foot of bed is removed so OB can gain better perineal access for performing episiotomy, delivering large baby, using forceps or vacuum, or getting access to emerging head to facilitate suctioning.

Once woman is positioned, vulva and perineum are cleansed.

Prepare or obtain an oxytocic medication such as oxytocin (Pitocin) so that it is ready to be administered immediately after expulsion of placenta.

OB may put on a cap, mask w shield/protective eyewear and shoe covers. After washing hands, she puts on sterile gown with waterproof front and sleeves and sterile gloves. Nurses may also need to wear caps, protective eyewear, masks, gowns and gloves. Woman may be draped with sterile drapes.

Mechanism of Birth: Vertex Presentation – 3 phases: 1) birth of head 2) birth of shoulders 3) birth of body and extremities.

With voluntary bearing-down efforts, head appears at introitus. Crowning occurs when widest part of head distends vulva just before birth. Immediately before birth, perineal musculature become greatly distended. If episiotomy necessary, done at this time to minimize soft-tissue damage. Local anesthetic may be administered.

OB may use hands-on approach to control birth of head, believing that guarding perineum results in gradual birth that will prevent fetal intracranial injury, protect maternal tissues and reduce postpartum perineal pain. Approach involves 1) applying pressure against rectum, drawing it downward to aid in flexing head as back of neck catches under symphsysis pubis 2) applying upward pressure from coccygeal region (modified Ritgen maneuver) to extend head during actual birth, thereby protecting musculature of perineum and 3) assisting mother with voluntary control of bearing-down efforts by coaching her to pant while letting uterine forces expel fetus.

Perineal Trauma Related to Childbirth – most acute injuries and lacerations of perineum, vagina, uterus and support tissues occur during childbirth. Alternative measures for perineal management, such as application of warm compresses and gentle perineal massage and stretching have been suggested to less degree of perineal lacerations and trauma. Perineal massage during last month of pregnancy has clear benefits of reducing perineal trauma during birth and pain afterward for women who had not given birth vaginally before. Cochrane review found that warm compresses may be beneficial in reducing incidence of 3rd and 4th degree lacerations.

Some degree of trauma to soft tissues of birth canal and adjacent structures occurs during every birth. Damage is more pronounced in nulliparous woman because tissues are firmer and more resistant. Heredity also a factor. Reddish hair, light skinned women not as readily distensible as that of darker skinned woman and healing may be less efficient. Other risk factors include maternal nutritional status, birth position, pelvic anatomy, fetal malpresentation and position, large infants, use of forceps or vacuum, prolonged 2nd stage, and rapid labor where there in insufficient time for perineum to stretch.

Some injuries to supporting tissues, whether acute or nonacute and whether repaired or note may lead to genitourinary and sexual problems later in life, pelvic relaxation, uterine prolapse, cystocele, rectocele, dyspareunia, urinary and bowel dysfunction. Kegels in prenatal and postpartum periods improves and restores tone and strength of perineal muscles.

Perineal lacerations – usually occur as fetal head is being born. Defined in terms of its depth.

  • 1st degree: extends through skin and vaginal mucous membrane but not underlying fascia and muscle
  • 2nd degree – extends through fascia and muscles of perineal body, but not anal sphincter
  • 3rd degree – involves anal sphincter
  • 4th degree: extends completely through rectal mucosa, disrupting both external and internal anal sphincters

Perineal injury often accompanied by small laceration on medial surfaces of labia minora below pubic rami and to sides or urethra and clitoris. Lacerations in this highly vascular area often result in profuse bleeding. 3rd and 4th degree lacerations must be carefully repaired so woman retains fecal continence. Simple perineal injuries usually heal without permanent disability, regardless of whether they were repaired. Repairing a new perineal injury to prevent future complications is easier than correcting long term damage.

Vaginal and Urethral Lacerations – vaginal lacerations often occur in conjunction w perineal lacerations. Tend to extend up the lateral walls and if deep enough, involve levator ani muscle. Additional injury may occur high in vaginal vault near level of ischial spines. Vault lacerations often circular and may result from use of forceps, rapid fetal descent or precipitous birth.

Cervical injuries – occur when cervix retracts over advancing fetal head. Occur at lateral angles of external os. Most shallow and bleeding minimal. Larger lacerations may extend to vaginal vault or beyond it into lower uterine segment; serious bleeding may occur. Extensive lacerations may follow hasty attempts to enlarge cervical opening artificially or to deliver fetus before full cervical dilation achieved. Injuries to cervix can have adverse effects on future pregnancies and childbirth.

Episiotomy – incision in perineum used to enlarge vaginal outlet. Use has steadily decreased in recent years due to lack of sound, rigorous research to support its benefits.   Approx. 10% of births. Less common in Europe and Canada, probably because more routine use of side-lying position for birth; this puts less tension on perineum, making possible a gradual stretching of perineum. Giving birth over intact perineum provides best outcomes (less blood loss, less risk of infection, less postpartum pain).

Midline (median) episiotomy most commonly used in U.S. effective, easily repaired, and generally least painful. Also associated with higher incidence of 3rd and 4th degree lacerations. Spincter tone is usually restored after primary healing and a good repair.

Mediolateral used in operative births when need for posterior extension likely. 4th degree laceration may be prevented, but 3rd degree may occur. Blood loss greater and repair more difficult and painful than w midline episiotomies. More painful in postpartum period and pain lasts longer.

Increasingly common practice is to support perineum manually during birth rather than performing episiotomy with goal of minimizing trauma. If tears occur, they are often smaller than episiotomy are repaired easily or do not need to be repaired at all, and heal quickly w less pain. Episiotomies associated with more posterior perineal trauma, suturing and healing complications and later pain w intercourse. Should be avoided whenever possible.

3rd stage of labor lasts from birth of baby until placenta is expelled.

Goal is prompt separation and expulsion of placenta, achieved in easiest, safest manner. Shortest stage of labor. Placenta is usually expelled within 10-15 min after birth of baby. if hasn’t been completed w in 30 min, placenta is considered to be retained and interventions to hasten its separation and expulsion are usually instituted.

Placenta is attached to decidual layer of basal plate’s thin endometrium by numerous fibrous anchor villi. After birth of fetus, strong uterine contractions and sudden decrease in uterine size cause placenta site to shrink. This causes anchor villi to break and placenta to separate from its attachments. Normally, first few strong contractions that occur after baby’s birth cause placenta to shear away from basal plate. A placenta cannot detach itself from a flaccid (relaxed) uterus because placental site is not reduced in size.

Placental Separation and Expulsion – depending on preference, midwife will use passive or active approach. Passive management involved patiently watching for signs that placenta has separate from uterine wall spontaneously and monitoring for spontaneous expulsion. This is commonly practiced in U.S. Active management practiced in many countries; includes administering oxytocic (Pitocin) when anterior shoulder is birthed or immediately following birth of fetus, clamping and cutting cord within 3 min after birth, and gently controlling cord traction following uterine contraction and separation of placenta. WHO and evidence based literature now recommends active management because it decreases rate of postpartum hemorrhage caused by uterine atony.

Woman is instructed to push when signs of separation have occurred. Woman should expel placenta during uterine contraction. Alternate compression and elevation of the fundus along with minimal, controlled traction on umbilical cord may also be used to facilitate delivery of placenta and amniotic membranes. Oxytocics usually administered after placenta is removed when active management of 3rd stage is not implemented because they stimulate uterus to contract, thereby helping to prevent hemorrhage.

Whether placenta first appears by its shiny fetal surface (Schultze mechanism) or turns to show its dark roughened maternal surface first (Duncan mechanism) is of no clinical importance.

After placenta and amniotic membranes emerge, OB examines them for intactness to ensure no portion remains in uterine cavity. Nurse will obtain sample of blood from umbilical cord to be used for determining baby’s blood type and Rh status.

Physician examines woman for any perineal, vaginal or cervical lacerations requiring repair. Nurse may need to assist by providing adequate lighting. If an episiotomy was performed, it will be sutured. Immediate repair promotes healing, limits residual damage and decreases possibility of infection. Woman usually feels some discomfort while OB carries out postbirth vaginal examination. Baby nurse performs quick assessment of newborn’s physical condition and places matching ID bands on mom and baby. weighing baby, eye prophylaxis, vitamin K injection can be delayed until after initial bonding time.

After any necessary repairs, cleanse vulvar area with warm water or normal saline, and apply perineal pad or ice pack to perineum. Reposition birthing bed and lower woman’s legs simultaneously from stirrups. Removed any drapes and place dry linen under woman’s buttocks. Provide her w clean gown and blanket, warmed if needed.

Some women have cultural beliefs about placenta, viewing care and disposal as way of protecting newborn from bad luck and illness. In Spanish its referred to as el companero. Request to take home sometimes conflicts with health care agency policies, esp those related to infection control and disposal of biologic wastes. Many cultures follow specific rules regarding disposal (burning, drying, burying, eating), site for disposal (in/near home) and timing of disposal (immediately after birth, time of day, astrologic signs). Disposal rituals may vary according to gender of child and length of time before another child is desired. Some cultures believe eating it is a way or restoring moms health after birth or ensuring high quality breast milk.

 

When uterine atony and excessive bleeding occur, additional interventions likely to be used are administration of IV fluids and oxytocic medication (Drugs that stimulate contraction).

Preventing Bladder Distention – uterine atony and excessive bleeding after birth can be the result of bladder distention. A full bladder causes uterus to be displaced above the umbilicus and well to one side of midline in the abdomen. It also prevents the uterus from contracting normally.

Women can be at risk of bladder distention resulting from urinary retention based on intrapartum factors including epidural, episiotomy , extensive vaginal or perineal lacerations, instrument assisted birth, or prolonged labor. Women who have had indwelling catheters, such as w cesarean, can experience some difficult as they initially attempt to void after the catheter is removed. Nurses aware of these risk factors can be proactive in preventing complications.

Nursing interventions for a postpartum woman focus on helping woman empty her bladder spontaneously as soon as possible. First priority is to assist woman to bathroom or onto a bedpan if she is unable to ambulate. Having woman listen to running water, placing her hands in warm water, or pouring water from a squeeze bottle over perineum may stimulate voiding. Other techniques include assisting woman into shower or sitz bath and encouraging her to void; relaxation techniques can also be helpful. Administering analgesics, if ordered, may be indicated because some women fear voiding because of anticipated pain. If these measures are unsuccessful, a sterile catheter may be inserted to drain urine.

Preventing Infection – nurses in postpartum setting are acutely aware of the importance of preventing infection. 1 important means of preventing infection is by maintaining a clean environment. Bed linens should be changed as needed. Disposable pads and drawsheets are changed frequently. Women should wear slippers when walking about to prevent contamination of the linens when they return to bed. Personnel must be conscientious about their hand hygiene to prevent cross-infection. Standard precautions must be practiced. Staff members w coughs, colds or skin infections (Cold sore) must follow hospital protocol when in contact w postpartum women. In many hospitals, staff members w open herpetic lesions, strep throat, conjunctivitis, upper respiratory infections or diarrhea are encouraged to avoid contact w moms and infants by staying home until condition is no longer contagious. Visitors w signs of illness not permitted to enter postpartum unit.

Perineal lacerations and episiotomies can increase the risk of infection as a result of interruption in skin integrity. Proper perineal care helps prevent infection in the genitourinary area and aids the healing process. Educating the woman to wipe from front to back (urethra to anus) After voiding or defecating is a simple first step. In many hospitals a squeeze bottle filled w warm water or antiseptic solution Is used after each voiding to cleanse perineal area. Woman should change her perineal pad from front to back each time she voids or defecates and wash her hands thoroughly before and after doing so.

Promoting Comfort – most women experience some degree of discomfort during the postpartum period. Common causes of discomfort include pain from uterine contractions (afterpains), perineal lacerations or episiotomy, hemorrhoids, sore nipples and breast engorgement. The woman’s description of the location, type and severity of her pain is the best guide in choosing appropriate interventions. To confirm the location and extent of discomfort, the nurse inspects and palpates areas of pain as appropriate for redness, swelling, discharge, and heat, and observes for body tension, guarded movements, and facial tension. Blood pressure, pulse and respirations can be elevated in response to acute pain. Diaphoresis can accompany severe pain. A lack of objective signs does not necessarily mean there is no pain because there can be a cultural component to the expression of pain. Nursing interventions are intended to eliminate the pain sensation entirely or reduce it to a tolerable level that allows the woman to care for herself and her newborn. Nurses may use nonpharmacologic and pharmacologic interventions to promote comfort. Pain relief is enhanced by using more than 1 method or route.

Nonpharmacologic interventions – various measures used to reduce discomfort. Distraction, imagery, therapeutic touch, relaxation, acupressure, aromatherapy, hydrotherapy, massage therapy, music therapy and TENS.

For women who are experiencing discomfort associate w uterine contractions, application of warmth (heating pad) or lying prone can be helpful. Interaction w the infant can also provide distraction and decrease this discomfort. Because afterpains are more severe during and after breastfeeding, interventions are planned to provide the most timely and effective relief. Simple interventions that can decrease discomfort associate w episiotomy or perineal lacerations include encouraging woman to lie on her side whenever possible. Others include application of ice pack; topical application (if ordered) of anesthetic spray or cream; cleansing w water from a squeeze bottle and a cleansing shower, tub bath or sitz bath. Many of these also effective for hemorrhoids, esp ice packs, sitz baths and topical applications (Such as witch hazel).

Sore nipples in breastfeeding moms most likely related to ineffective latch technique. Assessment and assistance w feeding can help alleviate. To ease discomfort, mother may apply topical preparations such as purified lanolin or hydrogel pads.

Breast engorgement can occur whether woman is breastfeeding or formula feeding. Discomfort may be reduced by applying ice packs or cabbage both (or both) to breasts, and wearing a well fitted support bra. Anti-inflammatory meds such as ibuprofen can also be helpful in relieving some of discomfort. Decisions about specific interventions for engorgement based on whether she chooses breastfeeding or bottle feeding.

Pharmacologic interventions – most providers order variety of analgesics to be administered as needed, including opioid and non-opioid (nonsteroidal anti-inflammatory drugs – NSAIDS). Some hospitals administer on a scheduled basis, esp if woman had perineal repair. Topical application of antiseptic or anesthetic ointment or spray can be used for perineal pain. Patient controlled analgesia (PCA) pumps and epidural analgesia commonly used to provide pain relief after cesarean birth.

Nurse should carefully monitor all women receiving opioids bc respiratory depression and decreased intestinal motility are side effects.

Many women want to participate in decisions about analgesia. Severe pain, however, can interfere w active participation in choosing pain relief measures.   If analgesics to be given, nurse must make clinical judgment of type, appropriate dosage, and frequency from medications ordered. Woman is informed of prescribed analgesics and common side effects.

 

Protecting Your Perineum form a Large tear or an Episiotomy: choose a caregiver who prefers to avoid episiotomies and has a low rate (less than 20%); good nutrition promotes healthy tissues, so eat well during pregnancy; perform perineal massage regularly for a few weeks before birth; when you push, bear down for only 5-7 seconds each time; use positions that put minimal strain on perineum – side lying, kneeling, hands and knees; pant lightly and listen to caregivers directions to avoid pushing while baby’s head and shoulders are being born.

  1. Vacuum extraction

Vacuum-Assisted Birth – or vacuum extraction, is a birth involving attachment of a vacuum cup to fetal head using negative pressure to assist in birth of head. Generally not used to assist birth before 34 weeks. Indications for use are same as those for outlet forceps. Prerequisites for use include a completely dilated cervix, ruptured membranes, engaged head, vertex presentation, and no suspicion of CPD. Types are defined the same as for forceps – by station and position of fetal head in relation to maternal pelvis. Advantages of vacuum-assisted compared w forceps-assisted are ease with which vacuum can be placed and need for less anesthesia. Its far easier to teach and to learn skills to safely use vacuum than to gain a similar level of skill w forceps.

Medical Management – Vacuum cup is applied to fetal head by physician. 2 types – 1 is self contained unit, which allows physician to both position cup on baby’s head and generate the desired amount of negative pressure to create a vacuum.   When other type is used, physician applies cup to baby’s head, after which nurse connects suction tubing attached to cup to wall suction or a separate hand pump and generates the amount of pressure requested by physician. With both devices, a caput develops inside the cup as the pressure is initiated. Woman is encouraged to push as traction is applied. Vacuum cup is released and removed after birth of head. If not successful, a forceps or cesarean usually performed.

Risks to newborn include cephalhematoma, scalp lacerations and subdural hematoma. These can be reduced by strict adherence to manufacturer’s recommendations for method of application, amount of pressure to be generated, and duration of application.   Maternal risks include perineal, vaginal or cervical lacerations and soft-tissue hematomas.

Nursing Interventions – nurse provides education and support for woman who had vacuum assisted birth. Nurse can prepare woman for birth and encourage her to remain active in birth process by pushing during contractions. FHR should be assessed frequently during procedure. Documentation of procedure in medical record is important and is often the nurse’s responsibility. Neonatal caregivers should be told that birth was vacuum assisted. After birth newborn observed for signs of trauma and infection at application site and for cerebral irritation (poor sucking or listlessness). Newborn can be at risk for hyeprbilirubinemia and neonatal jaundice as bruising resolves. Parents need to be reassured that caput succedaneum usually disappears in 3-5 days.

Assisting w Birth by Vacuum Extraction

  • Assess fetal heart rate frequently during procedure
  • Encourage woman to push during contractions
  • If responsible for generating pressure for vacuum do not exceed green zone indicated on pump. Verify w physician amount of pressure to be generated
  • Document # of pulls attempted, max pressure used and any pop offs that occur.

 

Vacuum Extraction and Forceps Delivery

A vacuum extractor is a silicone suction cup and forceps are long steel tongs. Vacuum used more often. Both use more frequently on those that received epidurals.

Caregiver pulls on it as woman pushes during contractions. Both instruments are generally safe for baby although bruising, swelling, and scarping of baby’s head often occur. Caregiver discontinues use of instruments if its obvious baby isn’t descending. At that point, a cesarean section becomes necessary.

  1. Valsalva breathing (directed breathing)

 

Bearing-Down Efforts: as fetal head reaches pelvic floor, most women experience urge to bear down. Woman will begin to exert downward pressure reflexively by contracting ab muscles while relaxing pelvic floor. It is an involuntary response to Ferguson reflex. Strong expiratory grunt or groan (vocalization) often accompanies pushing when woman exhales as she pushes. Shouldn’t be discouraged.

Prolonged breath-holding, or directed bearing down still common practice, often beginning at 10 cm dilation and before urge to bear down is perceived. Woman is coached to hold breath, close glottis and push while nurse counts to 10; this is strongly discouraged because may trigger Valsalva maneuver, which occurs when woman closes her glottis and increases intrathoracic and cardiovascular pressure. This reduces cardiac output and decreases perfusion of uterus and placenta. Adverse effects include fetal hypoxia and subsequent acidosis, increased risk for pelvic floor damage, perineal trauma.

Benefits of spontaneous pushing efforts include less fatigue and enhanced comfort. Essential that nurses advocate for delayed and spontaneous bearing-down efforts with woman in upright or lateral position.

Phrases to use: You’re doing so well; do it again. You are moving baby down. Follow what your body is telling you. Rather than push, push, push.

Monitor woman’s breathing so she does not hold breath for more than 6-8 sec at a time followed by slight exhale. Remind her to ventilate lungs by taking deep, cleansing breaths before and after each contraction. Bearing down while exhaling and taking breaths between bearing-down efforts helps maintain adequate oxygen levels for mom and fetus. Active pushing phase considered to be most physiologically stressful part of labor. Use nondirected spontaneous pushing to conserve energy and maximize effect of each bearing-down effort. Woman’s bearing-down efforts naturally will become more forceful and frequent as 2nd stage progresses to birth.

Woman may reach 2nd stage then experience a lack of readiness to complete process. May have doubts about readiness or desire to wait for support person or OB. Fear, anxiety, unfamiliar or painful sensations and behaviors during pushing may be other inhibiting factors. Fear baby will be in danger may be present. Address woman’s concerns and coach effectively.

To ensure slow birth of head, encourage woman to control urge to bear down by coaching her to take panting breaths or exhale slowly through pursed lips as baby’s head crowns. Woman needs simple, clear directions from one person at this point. Amnesia between contractions often occurs in 2nd stage.

  1. Third stage labor complications
  2. Postpartum hemorrhage

 

Postpartum Hemorrhage – continues to be leading cause of maternal morbidity and mortality in U.S. and throughout world. Can occur w little warning and is often not recognized until mom has profound symptoms.

  • PPH defined as loss of 500ml or more of blood after vaginal birth and 1000 ml or more after cesarean. Either a 10% change in hematocrit between admission for labor and postpartum or need for erythrocyte transfusion is also used to define PPH. Diagnosis often based on subjective observations, w blood loss often being underestimated by as much as 50%. Sentinel Event Alert: Preventing Maternal Death identified most preventable errors:
  • Failure to adequately control BP in hypertensive women
  • Failure to adequately diagnose and treat pulmonary edema in women w preeclampsia
  • Failure to pay attention to vital signs following cesarean
  • Hemorrhage following cesarean

PPH classified as early or late w respect to birth. Early, acute or primary occurs within 24 hrs of birth. Late or secondary occurs more than 24 hrs but less than 6 weeks after. Todays health care environment encourages shortened hospital stays which increases potential for acute episodes outside hospital setting.

Etiology and Risk Factors – when excessive bleeding observed, important to note color and consistency of blood as well as stage of labor. From birth until separation of placenta, character and quantity of blood passed can suggest excessive bleeding. Dark red blood likely of venous origin, perhaps from varices or superficial lacerations of birth canal. Bright blood is arterial and can indicate deep lacerations of the cervix. Spurts or blood w clots can indicate partial placental separation. Failure of blood to clot or remain clotted indicates a pathologic condition or coagulopathy such as disseminated intravascular coagulation (DIC).

Excessive bleeding can occur during period from separation of placenta to its expulsion or removal. Commonly such excessive bleeding is the result of incomplete placental separation, undue manipulation of the fundus, or excessive traction on the cord. After placenta has been expelled or removed, persistent or excessive blood loss usually is the result of uterine atony or prolapse of the uterus into the vagina. Late PPH can be the result of subinvolution of the uterus, endometritis, or retained placental fragments.

Uterine Atony – greatest risk for early PPH is during first hr after birth. During this time, large venous areas are exposed after placenta separates from uterine wall. Corpus or body of uterus is essentially a basket-weave of strong, interlacing smooth muscle bundles through which many maternal blood vessels pass. Bleeding is controlled by the contraction of smooth muscle in the uterus. If uterus is flaccid after detachment of all or part of the placenta, brisk venous bleeding occurs and normal coagulation of the open vasculature is impaired and continues until the uterine muscle is contracted. This marked hypotonia of uterus is called uterine atony.

Uterine atony is the leading cause of early PPH. Associated w high parity, polydydramnios, fetal macrosomia, and multiple gestations. In such condition, uterus is overstretched and contracts poorly after birth. Other causes include traumatic birth, use of halogenated anesthetic (halothane), magnesium sulfate, rapid or prolonged labor, chorioamnionitis, use of oxytocin for labor induction or augmentation, and uterine atony in a previous pregnancy.

 Risk Factors and Causes of Postpartum Hemorrhage

Uterine Atony

  • Overdistended uterus
    • Large fetus
    • Multiple fetuses
    • Hydramnios
    • Distention w clots
  • Anesthesia and analgesia
    • Conduction anesthesia
  • Previous history of uterine atony
  • High parity
  • Prolonged labor, oxytocin induced labor
  • Trauma during labor and birth
    • Forceps
    • Vacuum
    • Cesarean
  • Unrepaired lacerations of birth canal
  • Retained placental fragments
  • Ruptured uterus
  • Inversion of uterus
  • Placenta accrete, increta, percreta
  • Coagulation disorders
  • Placental abruption
  • Placenta previa
  • Manual removal of retained placenta
  • Magnesium sulfate admin during labor o postpartum period
  • Chorioamnionitis
  • Uterine subinvolution

Retained Placenta – when placenta has not been delivered w/in 30 min after birth despite gentle traction on umbilical cord and uterine massage, its described as retained. Initial management of retained placenta consists of manual separation and removal by OB. This involves the provider reaching into the uterus and gently separating the placenta from the uterine wall and removing it manually.   When mom has regional anesthesia for labor, supplementary anesthesia usually not needed. For other women, light admin of nitrous oxide and oxygen inhalation anesthesia or IV pain meds should be considered. A tocolytic medication such as nitroglycerin IV may be given to promote uterine relaxation. After removal of a retained placenta, woman is at continued risk for PPH and infection.

  • Fragments of placenta can remain in uterus after spontaneous separation of placenta during 3rd In this case, the woman will have excessive bleeding and uterus feels boggy (Soft) due to uterine atony. Ultrasonography can be used to detect placental fragments. Physician or nurse midwife may attempt manual exploration to remove the fragments; uterine curettage (Removal of uterine contents using curette or vacuum) may be necessary.
  • In rare instances, there is abnormal adherence of placenta to myometrium. Unknown why it occurs, but it is thought to result from zygote implantation in an area of defective endometrium so that no zone of separation exists between the placenta and decidua.   Attempts to remove placenta in the usual manner are unsuccessful and laceration or perforation of uterine wall can result, putting woman at great risk for severe PPH and infection.

 

Unusual placental adherence can be partial or complete. The following degrees of attachment are recognized:

  • Placenta accrete – slight penetration of myometrium
  • Placenta increta – deep penetration of myometrium
  • Placenta percreta – perforation of uterus

Placenta accrete is most common, with its incidence in associate w rise in cesarean birth rates. Other risk factors include placenta previa, prior uterine surgery, endometrial defects, submucosal fibroids, parity and maternal age. Placenta accrete can be diagnosed before birth using ultrasound and MRI, but often is not recognized until there is excessive bleeding after birth. Bleeding w complete or total placenta accrete may not occur unless manual removal of placenta is attempted. W more extensive involvement, bleeding becomes profuse when delivery of the placenta is attempted. Less blood is lost if diagnosis is made antenatally and no attempt is made to manually remove the placenta. Treatment includes blood component replacement therapy. Hysterectomy can be indicated for all 3 types of placental adherence if bleeding is uncontrolled.

Lacerations of the Genital Tract – lacerations of the cervix, vagina and perineum also are causes of PPH. Hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterine fundus. This bleeding can be a slow trickle, an oozing, or frank hemorrhage. Factors that influence the causes and incidence of obstetric lacerations of the lower genital tract include operative birth, precipitous or rapid birth, congenital abnormalities of the maternal soft tissue, and contracted pelvis. Other possible causes of lacerations are size, abnormal presentation and position of the fetus; relative size of the presenting part and the birth canal; previous scarring from infection, injury or operation; and vulva, perineal and vaginal varicosities.

Lacerations of the perineum are the most common of all injuries in the lower portion of the genital tract. These are classified as 1st, 2nd, 3rd or 4th degree. An episiotomy can extend to become either a 3rd or 4th degree laceration.

Prolonged pressure of fetal head on vaginal mucosa ultimately interferes w the circulation and may produce ischemic or pressure necrosis.   State of the tissues in combination w type of birth can result in deep vaginal lacerations, w consequent predisposition to vaginal hematomas.

Cervical lacerations usually occur at the lateral angles of the external os. Most are shallow, and bleeding is minimal. More extensive lacerations may extend into the vaginal vault or into the lower uterine segment.

Lacerations are usually identified and sutured immediately after birth. After the bleeding has been controlled, the care of the woman w lacerations of the perineum is similar to that for the woman w lacerations of the perineum is similar to that for women w episiotomies (analgesia as needed for pain and hot or cold applications as necessary). The need for increased fiber in the diet and increased intake of fluids is emphasized to reduce the risk of constipation. Stool softeners may be used to assist woman in reestablishing bowel habits w out straining and putting stress on suture lines.

Hematomas – pelvic hematomas (collection of blood in connective tissue) can be vulvar, vaginal or retroperitoneal in origin. Vulvar hematomas are most common. Pain is most common symptom, and most vulvar hematomas are visible. Vaginal hematomas occur more commonly in association w a forceps-assisted birth, an episiotomy or primigravidity.

Retroperitoneal hematomas are the least common but life threatening. They are caused by laceration of 1 of the vessels attached to the hypgastric artery, usually associated w rupture of a cesarean scar during labor. During the postpartum period, if the woman reports persistent perineal or rectal pain of a feeling of pressure in the vagina, a careful exam is made. However, a retroperitoneal hematoma can cause minimal pain and the initial symptoms can be signs of shock.

Hematomas are usually surgically evacuated. Once the bleeding has been controlled, usual postpartum care is provided w careful attention to pain relief, monitoring the amount of bleeding, replacing fluids, and reviewing lab results (hemoglobin and hematocrit).

Inversion of the Uterus – (turning inside out) after birth is a rare but potentially life-threatening complication. Varies form 1/2000 to 1/20000 births and differs depending on whether the birth was vaginal or cesarean and can recur w a subsequent birth. Can be incomplete, complete or prolapsed. Incomplete inversion cannot be seen; a smooth mass can be palpated through the dilated cervix. In complete inversion, the lining of he fundus crosses through the cervical os and forms a mass in the vagina. Prolapsed inversion of the uterus is obvious – a large, red, rounded mass (perhaps w the placenta attached) protrudes 20-30 cm outside the introitus.

Contributing factors to uterine inversion include fundal implantation of the placenta, vigorous fundal pressure, excessive traction applied to the cord, fetal macrosomia, short umbilical cord, tocolysis, prolonged labor, uterine atony, nulliparity and abnormally adherent placental tissue. The primary presenting signs of uterine inversion are sudden and include hemorrhage, shock, and pain. The uterus is not palpable abdominally. The uterus must be replaced into its proper position by OB.

Preventions – always the easiest, least expensive and most effective therapy – is esp appropriate for uterine inversion. The umbilical cord should not be pulled unless there are clear signs of placental separation.

Uterine inversion is an emergency situation requiring immediate interventions that include maternal fluid resuscitation, replacement of the uterus w/in the pelvic cavity, and correction of associated clinical conditions. Tocolytics or halogenated anesthetics may be given to relax the uterus before attempting replacement. Oxytocic agents are administered after the uterus is repositioned; broad-spectrum antibiotics are initiated. The woman’s response to treatment is monitored closely to prevent shock or fluid overload. If uterus has been repositioned manually, care must be take to avoid aggressive fundal massage.

Subinvolution of the Uterus – late postpartum bleeding can result from subinvolution of the uterus (delayed return of the enlarged uterus to normal size and function). Recognized causes of subinvolution include retained placental fragments nad pelvic infection. Signs and symptoms include prolonged lochial discharge, irregular or excessive bleeding and sometimes hemorrhage. A pelvic exam usually reveals a larger than normal uterus that can be boggy.

Treatment of subinvolution depends on the cause. Ergonovine (Ergotrate) or methylergonovine (Methergine), .2mg every 3-4 hrs for 24-48 hrs, is often used. Dilation and curettage (D&C) may be performed to remove retained placental fragments or to debride the placental site. If the cause of subinvolution is infection, antibiotic therapy is needed.

Care Management – Assessment: early recognition and treatment of PPH are critical to care management. The first step is to evaluate the contractility of the uterus. If uterus is hypotonic or boggy, management is directed toward increasing contractility and minimizing blood loss.

If uterus is firmly contracted and bleeding continues, the source of bleeding still must be identified and treated. Assessment may include visual or manual inspection of the perineum, the vagina, the uterus, the cervix, or the rectum, as well as lab studies (hemoglobin, hematocrit, coagulation studies, platelet count). Treatment depends on source of bleeding.

Medical Management – initial intervention in management of excessive postpartum bleeding due to uterine atony if firm massage of uterine fundus. Expression of any clots in the uterus, elimination of bladder distention and continuous IV infusion of 10-40 units of oxytocin added to 1000 ml of lactated Ringer’s or normal saline solution are also primary interventions. If uterus fails to respond to oxytocin, other uterotonic medications are administered. Misoprostol (Cytotec), a synthetic prostaglandin E1 analog, if often use. An advantage is that it can be given rectally, sublingually or orally. Methylergonovine may be given IM to produce sustained uterine contractions. A derivative of prostaglandin F2a (carboprost tromethamine) may be given IM. Can also be given intramyometrially at cesarean birth or intraabdominally after vaginal birth. Prostglandin E2 (Dinoprostone) vaginal or rectal suppository can be used. In addition to medications used to contract uterus, rapid admin of crystalloid solutions or blood or blood products or both will be needed to restore woman’s intravascular volume.

Use of ergonovine or methylergonovine is contraindicated in presence of hypertension or cardiovascular disease. Prostaglandin F2a should not be given to women w history of asthma as it can cause bronchoconstriction.

Oxygen can be given by nonrebreather face mask to enhance oxygen delivery to cells. An indwelling urinary catheter is usually inserted to monitor urine output as a measure of intravascular volume. Lab studies usually include a CBC w platelet count, fibrinogen, fibrin split products, prothrombin time, and partial thromboplastin time. Blood type and antibody screen are done if not previously performed.

If bleeding persists, bimanual compression may be performed by OB. This involves inserting a fist into the vagina and pressing the knuckles against the anterior side of the uterus, and then placing the other hand on the abdomen and massaging the posterior uterus with it. If the uterus still does not become firm, the provider performs manual exploration of the uterine cavity for retained placental fragments.

Surgical Management – if preceding procedures ineffective, surgical mgmt. needed. Options include uterine tamponade (uterine packing or intrauterine tamponade balloon), bilateral uterine artery ligation, ligation of utero-ovarian arteries and infundibulopelvic vessels, and selective arterial embolization. Uterine compression suturing (B-Lynch or Hayman vertical sutures) may be performed and is sometimes combined w a tamponade balloon. If other treatment measures are ineffective, hysterectomy likely needed.

Nursing Interventions – nurse must be alert to symptoms of hemorrhage and be prepared to act quickly to minimize blood loss. Astute assessment of circulatory status can be done w noninvasive monitoring. Nursing diagnoses, expected outcomes of care, and interventions are based on cause of PPH.

Woman and family will be anxious about condition. Nurse can intervene by calmly providing explanations about interventions being performed and the need to act quickly.

Once woman’s condition is stabilized and she has begun recovery process, prep for discharge made. Discharge instructions for woman w PPH similar to those for any postpartum woman. In addition, woman should be told she will prob feel fatigue, even exhaustion and will need to limit physical activities to conserve her strength. She may need instructions about increasing her dietary iron and protein intake and iron supplementation to rebuild lost RBC volume. May need assistance w infant care and household activities until she has regained strength. Nurse should assess moms anticipation of support from family and friends and help mom plan how to ask for help when returning home. Some moms w PPH have problems w delayed lactogenesis, insufficient milk production or PPD. Referrals to follow up care or community resources may be needed, including lactation support or postpartum doula service.

 

Postbirth hemorrhage -> assessment to determine source of bleeding and signs of shock -> anticipate lab studies: CBC, blood typing and crossmatch, coagulation studies ->establish venous access/verify patency of venous access and start IV fluids ->

  • Placenta removed -> fundal massage
    • Fundus boggy -> empty urinary bladder-> give uterotonics as ordered
      • Uterus firms -> continue assessments for maternal hemodynamic status
      • Atony persists -> start supplemental oxygen -> repeat lab studies -> anticipate fluid/blood replacement therapy -> anticipate surgical intervention
    • Uterus firm -> assess for cervical or vaginal lacerations/hematoma -> anticipate and assist w repair -> bleeding continues -> start supplemental oxygen -> repeat lab studies -> anticipate fluid/blood replacement therapy -> anticipate surgical intervention
  • Placenta retained -> anticipate need for anesthesia -> give tocolytic as ordered -> anticipate and assist w manual removal of placenta -> give uterotonics as ordered -> if bleeding continues or signs and symptoms of shock -> start supplemental oxygen -> repeat lab studies -> anticipate fluid/blood replacement therapy -> anticipate surgical intervention
  • Suspected coagulopathy -> assess for underlying cause and start supplemental oxygen -> continuous assessment of maternal hemodynamic status -> anticipate fluid/blood replacement therapy -> anticipate pharmacologic management: antibiotics, vasoactive drugs, uterotonic agents -> anticipate surgical intervention

Medication Guide – Uterotonic Drugs to Manage Postpartum Hemorrhage

Drug/ Action/ Side Effects / Contraindications/ Dosage and Route/ Nursing Considerations

  • Oxytocin (Pitocin): contraction of uterus; decreases bleeding/ infrequent: water intoxications, nausea and vomiting / None for PPH/ 10-20 units/L up to 80 units/L diluted in lactated Ringer’s solution or normal saline at 125-200 milliunits/min IV; or 10-20 units IM / continue to monitor vaginal bleeding and uterine tone
  • Misoprostol (Cytotec): contraction of uterus/ headache, nausea, vomiting, diarrhea, fever, chills/ none/ 600-1000 mcg rectally once or 400 mcg sublingually or PO once / continue to monitor vaginal bleeding and uterine tone
  • Methylergonovine (Methergine): contraction of uterus/ hypertension, hypotension, nausea, vomiting, headache / hypertension, preeclampsia, cardiac disease/ .2 mg IM q2-rh up to 5 doses; may also be given intrauterine or orally/ check bp before giving, and do not give if >140/90 mm Hg; continue monitor vaginal bleeding and uterine tone
  • 15-Methylprostaglandin F2a (Prostin/15 m; Carboprost, Hemabate): contraction of uterus / headache, nausea and vomiting, fever, chills, tachycardia, hypertension, diarrhea / avoid w asthma or hypertension / 250 mcg IM or intrauterine injection every q15-90 min up to 8 doses / continue to monitor vaginal bleeding and uterine tone
  • Dinoprostone (Prostin E2): contraction of uterus / headache, nausea and vomiting, fever, chills, diarrhea / use w caution w history of asthma, hypertension or hypotension / 20 mg vaginal or rectal suppository q2h / continue to monitor vaginal bleeding and uterine tone

Hemorrhagic (Hypovolemic) Shock – Hemorrhage can result in hemorrhagic (hypovolemic) shock. Shock is an emergency situation in which the perfusion of body organs can become severely compromised and death can occur. Physiologic compensatory mechanisms are activated in response to hemorrhage. The adrenal glands release catecholamines, causing arterioles and venules in the skin, lungs, gastrointestinal tract, liver and kidneys to constrict. The available blood flow is diverted to the brain and heart and away from other organs, including the uterus. If shock is prolonged, the continued reduction in cellular oxygenation results in accumulation of lactic acid and acidosis (from anaerobic glucose metabolism.   Acidosis (lowered serum pH) causes arteriolar vasodilation; venule vasoconstriction persists. A circular pattern is established (decreased perfusion, increased tissue anoxia and acidosis, edema formation and pooling of blood further decrease the perfusion). Cellular death occurs.

 

Postpartum Hemorrhage – Excessive loss of blood (more than 500 milliliters or 2 cups) during first 24 hours after birth.

  • Occurs in 20% of women, making it the most common problem during 3rd stage

Treatment depends on cause. 3 main causes: uterine atony; vaginal, cervical or perineal lacerations; and retained placenta or placenta fragments.

Treatment may require IV fluids or a blood transfusion if bleeding is severe. Excessive loss of blood may lead to symptoms of shock, such as rapid pulse, pale skin, trembling, faintness, feeling cold and sweating.

  1. Uterine Atony

Postpartum Assessment and Signs of Potential Complications

Assessment/Normal Findings/Signs of Potential Complications

  • BP: consistent w BP baseline during pregnancy; can have orthostatic hypotension for 48 hrs/ hypertension: anxiety, preeclampsia, essential hypertension. Hypotension: Hemorrhage
  • Temp: 97.2- 100.4F/ >100.4F after 24 hrs; infection
  • Pulse: 50-90 bpm/ tachycardia: pain, fever, dehydration, hemorrhage.
  • Respiration: 16-24 bpm/ bradypnea: effects of opioid medication. Tachypnea: anxiety; may be sign of respiratory disease
  • Breath sounds: clear to auscultation/ crackles; possible fluid overload
  • Breasts: days 1-2 soft, days 203 filling; days 3-5 full, soften w breastfeeding (milk is in) / firmness, heat, pain; engorgement
  • Nipples: skin intact, no soreness reported/ redness, bruising, cracks, fissures, abrasions, blisters, usually associated w latching problems
  • Uterus (Fundus): firm, midline; first 24 hrs at level of umbilicus, involutes – 1 cm/day / soft, boggy, higher than expected level; uterine atony. Lateral deviation; distended bladder
  • Lochia: days 1-3 rubra (Dark red), days 3-10 serosa (Brownish red or ink) after 10 days alba (yellowish white). Amount: scant to moderate. Few clots. Fleshy odor. / large amount of lochia, large clots: uterine atony, vaginal or cervical laceration. Foul odor: infection. Pronounced edema, bruising, hematoma. Redness, warmth, drainage: infection.
  • Perineum: minimal edema; laceration or episiotomy; edges approximated. Pain minimal to moderate: controlled by analgesics, nonpharmacologic techniques or both. / Excessive discomfort first 1-2 days: hematoma. After day 3: infection
  • Rectal area: no hemorrhoids, If present – soft and pink / discolored hemorrhoid tissues, severe pain: thrombosed hemorrhoid
  • Bladder: able to void spontaneously, no distention, able to empty completely, no dysuria. Diuresis begins 12 hrs after birth; can void 3000 ml/day. / Dysuria, frequency, urgency: infection
  • Abdomen and bowels: abdomen soft, active bowel sounds in all quadrants. Bowel movement by day 2 or 3 after birth. Cesarean: incision dressing clean and dry; suture line intact/ no bowel movement by day 3 or 4; constipation, diarrhea. Abdominal incision – redness, edema, warmth, drainage, infection
  • Legs: deep tendon reflexes (DTR) 1-2, peripheral edema possibly present, human sign negative. / DTRS>3: preeclampsia
  • Energy levels: able to care for self and infant; able to sleep./ lethargy, extreme fatigue, difficulty sleeping: postpartum depression
  • Emotional status: excited, happy, interested or involved in infant care/ sad, tearful, disinterested in infant care: postpartum blues or depression

Preventing Excessive Bleeding – all women who have given birth at risk for excessive bleeding that can progress to postpartum hemorrhage. Most frequent causes is uterine atony (Failure of uterine muscle to contract firmly). 2 most important interventions are maintaining good uterine tone and preventing bladder distention. If uterine atony occurs, the relaxed uterus distends w blood and clots, blood vessels in the placental site are not clamped off, and excessive bleeding results. Although cause not always clear, it often results from retained placenta fragments.

Excessive blood loss after birth can also be caused by vaginal or vulvar hematomas or unrepaired lacerations of the vagina or cervix. These potential sources might be suspected if excessive vaginal bleeding occurs in the presence of a firmly contracted uterus.

Fig 21-3 Blood loss after birth is assessed by extent of perineal pad saturation: scant )<2.5 cn), light (<10 cm), moderate (>10 cm) or heavy (1 pad saturated within 2 hrs).

A perineal pad saturated in 15 min or less and pooling of blood under the buttocks are indications of excessive blood loss, requiring immediate assessment, intervention and notification of health care provider.

Accurate visual estimation of blood loss is an important nursing responsibility. Blood loss is usually described subjectively as scant, light, moderate, or heavy (profuse).

Although postpartal blood loss can be estimated by observing the amount of drainage on a perineal pad, judging the amount of lochial flow is difficult if based only on observation of perineal pads. More objective estimates include measuring serial hemoglobin or hematocrit values, weighting blood clots and items saturated w blood (1 ml = 1 g), and establishing how many ml are required to saturate the perineal pads being used.

Nurses in general tend to overestimate rather than underestimate blood loss. Different brands of perineal pads vary in their saturation volume and soaking appearance. For ex, blood placed on some brands tend to soak down into the pad, whereas on other brands it tends to spread outward. Nurses should determine saturation volume and soaking appearance for brands use in their institution so they can improve accuracy of blood loss estimation.

Nurse always checks for blood under buttocks as well as perineal pad. Although amount on perineal pad may appear small, blood can flow between buttocks onto linens. Excessive bleeding can go undetected

When excessive bleeding occurs, vital signs are monitored closely. Blood pressure is not a reliable indicator of impending shock from early postpartum hemorrhage because compensatory mechanisms prevent a significant drop in blood pressure until the woman has lost 30-40% of her blood volume. Respirations, pulse, skin condition, urinary output and level of consciousness are more sensitive means of identifying hypovolemic shock. The frequent physical assessments performed during 4th stage of labor are designed to provide prompt identification of excessive bleeding. Nurses maintain vigilance for excessive bleeding throughout the hospital stay as they perform periodic assessment of the uterine fundus and lochia.

Hypovolemic Shock –

Signs and Symptoms:

  • Persistent significant bleeding occurs – perineal pad is soaked w/in 15 min; may not be accompanied by a change in vital signs or maternal color or behavior
  • Woman states she feels weak, lightheaded, funny or nauseated or that she see stars
  • Woman begins to act anxious or exhibits air hunger
  • Woman’s skin color turns ashen or grayish
  • Skin feels cool and clammy
  • Pulse rate increases
  • Bp decreases

Interventions

  • Notify health provider
  • If uterus is atonic, massage gently and expel clots to cause it to contract; compress uterus manually, as needed, using 2 hands. Add oxytocic agent to IV drip, as ordered
  • Give oxygen by nonrebreather face mask at 10L/min
  • Tilt woman onto her side or elevate the right hip; elevate legs to at least 30 degree angle
  • Provide additional or maintain existing IV infusion of lactate Ringer’s solution or normal saline solution to restore circulatory volume (woman should have 2 patent IV lines; insert second IV using 16-18 gauge IV catheter)
  • Administer blood or blood products, as ordered
  • Monitor vital signs
  • Insert an indwelling urinary catheter to monitor kidney perfusion
  • Administer emergency drugs, as ordered
  • Prepare for possible surgery or other emergency treatments or procedures
  • Document the incident, medical and nursing interventions instituted, and woman’s response to interventions

Maintaining Uterine Tone – major intervention to alleviate uterine atony and restore uterine muscle tone is stimulation by gently massaging the fundus until firm. Fundal massage can cause a temporary increase in the amount of vaginal bleeding seen as pooled blood leaves the uterus. Clots also can be expelled. The uterus can remain boggy even after massage and clot expulsion.

Fundal massage can be a very uncomfortable procedure. If the nurse explains the purpose of fundal massage as well as the causes and dangers of uterine atony, the woman will likely be more cooperative. Teaching the woman to massage her own fundus enables her to maintain some control and decrease her anxiety.

When uterine atony and excessive bleeding occur, additional interventions likely to be used are administration of IV fluids and oxytocic medications (drugs that stimulate contraction of uterine smooth muscle).

 

Uterine Atony – poor uterine muscle tone and its most frequent cause of postpartum hemorrhage. If uterus doesn’t contract after birth, caregiver will massage it to encourage contractions. Nursing baby or lightly stroking nipples also helps contract uterus by stimulating release of oxytocin. If these measures don’t control bleeding, caregiver may give you Pitocin to promote contractions.

  1. Lacerations

Interventions for Episiotomy, Lacerations and Hemorrhoids:

Cleansing

  • Wash hands before and after cleansing perineum and changing pads
  • Wash perineum w mild soap and warm water at least 1x daily
  • Cleanse from symphysis pubis to anal area
  • Apply peripad from front to back, protecting inner surface of pad from contamination
  • Wrap soiled pad and place in covered waste container
  • Change pad w each void or defecation or att least 4x/day
  • Assess amt and character of lochia w each pad change

Ice pack

  • Apply covered ice pack to perineum from front to back:
    • During 1st 24 hrs to decrease edema formation and increase comfort
    • After first 24 hrs following birth as need to provide anesthetic effect

Squeeze Bottle

  • Demonstrate use and assist woman
  • Fill w tap water warmed to 100.4F (Comfortably warm on wrist)
  • Instruct woman to position nozzle between legs so squirts of water reach perineum as she sits on toilet seat. Takes whole bottle to cleanse perineum
  • Remind her to blot dry w tp or clean wipes
  • Remind her to avoid contamination from anal area by wiping front to back
  • Apply clean pad

Sitz Bath

Built in Type

  • Prepare bath by thoroughly scrubbing w cleaning agent and rinsing
  • Pad w towel before filling
  • Fill 1/3-1/2 full w water of correct temp (1..04-105/1F). Some women prefer cool sitz baths. Ice is added to water to lower temp to comfortable level
  • Encourage woman to use at least 2x a day for 20 min
  • Place call bell within easy reach
  • Teach woman to enter bath by tightening gluteal muscles and keeping them tightened and then relaxing them after she is in bath
  • Place dry towels within reach
  • Ensure privacy
  • Check woman in 15 min

Disposable Type

  • Clamp tubing and fill bag w warm water
  • Raise toilet seat; place bath in bowl w overflow opening directed toward back of toilet
  • Place container above toilet bowl
  • Attach tube into groove at front of bath
  • Loosen tube clamp to regulate rate of flow; fill bath ~ ½ full; continue as for built in sitz bath

Topical Applications

  • Apply anesthetic cream or spray after cleansing perineal area: use sparingly 3-4x day
  • Apply witch hazel pads (Tucks) after voiding or defecating; woman pats perineum dry from front to back and applies witch hazel pads
  • Apply hemorrhoidal cream as ordered to anal area after cleansing

 

Promoting Comfort – Nonpharmacologic Interventions (488) – distraction, imagery, therapeutic touch, relaxation, acupressure, aromatherapy, hydrotherapy, massage, music, TENS.

For women experiencing discomfort w uterine contractions, application of warmth (heating pad) or lying prone can be helpful. Interaction w the infant can also provide distraction and decrease this discomfort. Because afterpains are more severe during and after breastfeeding, interventions are planned to provide the most timely and effective relief. Simple interventions that can decrease discomfort w episiotomy or perineal lacerations include encouraging woman to lie on her side whenever possible. Others include application of ice pack; topical application (if ordered) or anesthetic spray or cream; cleansing w water from squeeze bottle; and a cleansing shower, tub bath, or sitz bath. Many of these also effective for hemorrhoids, esp ice packs, stiz baths and topical applications (such as witch hazel).

Sore nipples in breastfeeding moms are most likely related to ineffective latch technique. Assessment and assistance w feeding can help alleviate cause. To ease discomfort associated w sore nipples, moms may apply topical preparations such as purified lanolin or hydrogel pads.

Breast engorgement can occur whether woman is breastfeeding or formula feeding. Discomfort may be reduced by applying ice packs or cabbage leaves (or both) to breasts, and wearing a well0fitted support bra.   Anti-inflammatory meds such as ibuprofen can also be helpful in relieving some of the discomfort. Decisions about specific interventions for engorgement based on whether mom is breastfeeding or bottle feeding.

Pharmacologic Interventions – most providers routinely order variety of analgesics to be administered as needed, including both opioid and nonopiod (nonsteroidal anti-inflammatory drugs (NSAIDS). In some hospitals, there are administered on a scheduled basic, esp if woman had perineal repair. Topical application of antiseptic and anesthetic ointment or spray can be used for perineal pain. Patient-controlled analgesia (PCA) pumps and epidural analgesia are commonly used to provide pain relief after cesarean.

Nurse should carefully monitor all women receiving opioids bc respiratory depression and decreased intestinal motility are side effects.

Many women want to participate in decisions about analgesia. Severe pain can interfere w active participation in choosing pain relief measures. If analgesic is to be given, the nurse must make a clinical judgment of type, appropriate dosage, and frequency from medications ordered. Woman is informed of prescribed analgesic and its common side effects; this teaching is documented.

Breastfeeding moms often have concerns about the effects of an analgesic on infant. Although nearly all drugs present in maternal circulation also found in breast milk, many considered relatively safe.

Lacerations – tears of cervix, vagina or perineum may occur, regardless of whether you had an episiotomy. If have lacerations, they’ll be sutured to control bleeding. Vagina may be packed with sterile gauze to further stop blood flow.

  1. Retained placenta

Retained Placenta – when placenta has not been delivered w/in 30 min after birth despite gentle traction on umbilical cord and uterine massage, it is described as retained. Initial management of a retained placenta consists of manual separation and removal by the physical or nurse-midwife. This involves the provider reaching into the uterus and gently separating the placenta from uterine wall and removing it manually. When mom has regional anesthesia for labor, supplementary anesthesia is usually not needed. For other women, admin of light nitrous oxide and oxygen inhalation anesthesia or IV pain meds should be considered. A tocolyitc medication such as nitroglyecerin IV may be given to promote uterine relaxation. After removal of a retained placenta, woman at continue risk for PPH and infection.

Fragments of placenta can remain in uterus after spontaneous separation of placenta during 3rd stage. In this case, the woman will have excessive bleeding and uterus feels boggy (Soft) due to uterine atony. Ultrasonography can be used to detect placental fragments. Physician or nurse midwife may attempt manual exploration to remove the fragments; uterine curettage (Removal of uterine contents using curette or vacuum) may be necessary.

In rare instances, there is abnormal adherence of placenta to myometrium. Unknown why it occurs, but it is thought to result from zygote implantation in an area of defective endometrium so that no zone of separation exists between the placenta and decidua.   Attempts to remove placenta in the usual manner are unsuccessful and laceration or perforation of uterine wall can result, putting woman at great risk for severe PPH and infection.

Risk Factors and Causes of Postpartum Hemorrhage

Uterine Atony

  • Overdistended uterus
    • Large fetus
    • Multiple fetuses
    • Hydramnios
    • Distention w clots
  • Anesthesia and analgesia
    • Conduction anesthesia
  • Previous history of uterine atony
  • High parity
  • Prolonged labor, oxytocin induced labor
  • Trauma during labor and birth
    • Forceps
    • Vacuum
    • Cesarean
  • Unrepaired lacerations of birth canal
  • Retained placental fragments
  • Ruptured uterus
  • Inversion of uterus
  • Placenta accrete, increta, percreta
  • Coagulation disorders
  • Placental abruption
  • Placenta previa
  • Manual removal of retained placenta
  • Magnesium sulfate admin during labor o postpartum period
  • Chorioamnionitis
  • Uterine subinvolution

Uterine Atony – greatest risk for postpartum hemorrhage is during 1st hr after birth. Large venous areas exposed after placenta separates from uterine wall. Corpus or body of uterus is essentially a basket weave of strong, interlacing smooth muscle bundles through which many large maternal blood vessels pass. Bleeding is controlled by contraction of smooth muscle in uterus. If uterus is flaccid after detachment of all or part of the placenta, brisk venous bleeding occurs and normal coagulation of the open vasculature is impaired and continues until the uterine muscle is contracted. This marked hypotonia of uterus called uterine atony.

Uterine atony is leading cause of early PPH. Associated w high parity, polyghydramnios, fetal macrosomia, and multiple gestation. In such conditions, uterus is over-stretched and contracts poorly after birth. Other causes include traumatic birth, use of halogenated anesthetic (halothane), magnesium sulfate, rapid or prolonged labor, chorioamnionitis, use of oxytocin for labor induction or augmentation, and uterine atony in a previous pregnancy.

 

Retained Placenta or Placental Fragments- if placenta or fragments of it aren’t expelled form uterus, they interfere with postpartum contractions and allow blood to flow freely through vessels at the site where the placenta attached to your uterine wall. Placenta or fragments are removed, receive Pitocin or another medication to contract your uterus and uterus is massaged to promote further contractions. Can continue treatment by massaging uterus yourself and by breastfeeding baby. in rare cases, placenta cant be separated from the uterine wall (placenta accrete). The only safe treatment for this serious complication may be a hysterectomy (removal of uterus).

  1. Cesarean birth – ICEA Position Paper on Cesarean Birth see end
  2. Risks and benefits

 

  1. 
Surgical procedure
  1. Recovery
  1. Vaginal birth after cesarean (VBAC)

Vaginal Birth after Cesarean (VBAC) – if had a cesarean and are pregnant again, need to decide between planning another cesarean or planning a trial of labor after cesarean (TOLAC), in which labor is allowed to begin and progress with the hopes of having a vaginal birth after cesarean (VBAC).

Making the Choice Between VBAC and Repeat Cesarean – discuss with caregiver; medial benefits and risk specifics to your situation. Because caregivers views on VBAC vary widely, may want to consult with multiple providers.

Medical Benefits and Risks of VBAC vs Repeat Cesarean – benefits of TOLAC to mother might be balanced by increased risks to baby; benefits of cesarean to baby might be balanced by increased risks to mother. When they are medically equivalent options, woman’s preference should be respected. ACOG agreed VBAC is a safe and appropriate choice for most option.

Need to examine relative rare but real risk of uterine rupture, the separation or opening of the scar from the uterine incision. If rupture occurs, it often results in a hysterectomy for mother (14-33% risk) and can lead to death of baby (6% risk).

With TOLAC, risk of rupture is 325/100,000 or 1/3 of 1%; planned repeat cesarean risk of rupture drops to 26/100,000. Overall risk of baby’s death is 130/100,000 for TOLAC and 50/1000,000 for repeat cesarean. It’s similar to risk of baby’s death for first time mother laboring with unscarred uterus (100/100,000).

Even with increased chance of rupture, vaginal birth carries fewer overall risks that surgical birth. TOLAC carries a lower risk of hysterectomy, blood transfusion, and deep vein thrombosis; it also a shorter hospital stay. Overall risk of maternal death is less than 4/100,000 for TOLAC and more than 13/100,000 for repeat cesarean.

If risk of uterine rupture high or chances of having other complications in labor are high, planned cesarean may be best. It has fewer risks than an unplanned cesarean that occurs after a failed TOLAC. If risk of uterine rupture is low and chances of VBAC success are favorable, best option may be to attempt VBAC.

What Influences My Chance of Uterine Rupture – chance relatively small (1/3 of 1% for TOLAC):

  • Chance of rupture lowest for woman who has had only 1 prior cesarean with a low transverse scar and who hasn’t been induced
  • Chance or rupture higher if woman has had more than 1 prior cesarean, had an infection after prior cesarean, had cesarean less than 18 months ago or has had labor induced
  • Chance highest (and too risky) for woman who has had vertical incision or inverted T or J shaped incision for prior cesarean, had a rupture from previous labor that caused problems, or had ultrasound scan that found uterine scar to be less than 2.5 millimeters thick

Monitoring for and Managing Uterine Rupture – during VBAC labor, caregiver closely monitors both mom and baby for uterine rupture, which she can diagnose by observing baby’s heart rate, shape of mother’s abdomen and moms BP. If caregiver suspects rupture, mom has emergency cesarean to prevent excessive bleeding and distress to baby. Majority of babies are fine after rupture.

Likelihood of VBAC Success– most woman who plan TOLAC achieve a vaginal birth (60-94%). More likely if woman is <40 and has had prior vaginal birth and reason for previous cesarean hasn’t recurred and labor is progressing well. Less likely if:

  • Mother has had multiple prior cesareans, has complicating medical conditions, or obese
  • Gestation >40 weeks and baby estimated to weigh >9 lbs
  • Labor induced/augmented

Improving Chances of Having Successful VBAC:

  • Choose caregiver who has high VBAC attempt rate and success rate of 70%+
  • Consider hiring doula who has had VBAC herself or has worked with women VBACs
  • Take childbirth refresher class or VBAC class
  • If cesarean was traumatic, contact local branch of ICAN – International Cesarean Awareness Network; mission is to prevent unnecessary cesareans through education, provide support for recovery and promote VBAC. ican-online.org. see paper “Your Right To Refuse: What do to if your hospital has banned VBAC”
  • Try to minimize medications for pain relief and use interventions only if necessary
  • Review “10 steps to improve chances of having a safe and satisfying birth” and “Reducing chances of having a cesarean”

Availability of VBAC – before 1980, common though was “once a cesarean, always a cesarean”. From 80s-90s, experts recommended VBAC because they believed it was safer than repeat cesarean. In 99 and 08, experts recommended hospitals permit VBAC only when physician, staff, anesthesia were immediately available to provide emergency cesarean. Due to staffing, many hospital policies turned against it. By early 2010, 1/3 of hospitals no longer permitted VBAC and ½ of physicians stopped offering it as an option. In July 2010, ACOG changed their stance, stating if laboring woman arrived at hospital that didn’t support TOLAC, she shouldn’t be forced to have a repeat cesarean against her will. However, physician uncomfortable with it may refer her to another physician. Search for caregiver that supports decision or consider relocation to friend/relative home near hospital that supports it.

Emotional Reactions when deciding between repeat cesarean and VBAC – because fear/anxiety can slow/complicate labor, its best to address during pregnancy

  • Fear – may fear labor pain, long labor, uterine rupture, complications, another cesarean, failure to deliver normally or simply the unknown. Discuss fears with caregiver, childbirth educator, doula, or cesarean support group. They can help you identify the most distressing parts of your previous birth and help you plan how to avoid or address them. You may plan not to wait for hours before having cesarean if have another long labor that doesn’t progress
  • Shame/guilt – talk with others who understand your feelings so you can approach this birth with fresh perspective
  • Lack of confidence – remember each pregnancy and birth is different. Get to know women who’ve had successful VBACs. Perhaps they visualized the birth experience they hoped for
  • Feeling pressured – may feel pressured to make one decision or another. You have the right to make an informed decision. Only you can make the decision that’s best for you and your family
  • Stress in labor – specific events in VBAC may increase stress:
    • When early labor is underway, you may suddenly second guess whether it’s a good idea. Think of ways to deal with this beforehand
    • Particular events in labor may trigger flashbacks. Don’t suppress them, even in unpleasant. Acknowledge and note how things are different this time
    • Big hurdle may be reaching point in labor that led to previous cesarean. Until you pass that point, may question ability to birth vaginally. After you’ve passed it, breathe a sign a relief and enjoy a boost of optimism

Having the Best Possible Cesarean Birth:

  • Educate yourself – learn about procedure from books, classes and discussions with caregiver. Learn birthplace policies and regulations
  • If planned cesarean is necessary, prepare in advance – eat well and exercise regularly. The more physically fit before surgery, the quicker recovery
    • Tour hospital, including special care nursery. Ask to have an lab work, tests and paperwork done before day of surgery. Meet with anesthesiologist to discuss options and learn what medications he will use
    • If hospital allows for 2 support people, ask for a friend/family member to join. Or consider doula. Her calm, familiar presence and knowledge of cesareans can reassure you. After baby is born, she can remain by your side while partner is with baby
    • Take breastfeeding class with partner so you both know ways to help make nursing after cesarean easier
  • Wait for labor to begin (or at least wait until 39th week) – if caregiver recommends cesarean before labor, be certain there are clear medical reasons. There are advantages to waiting until labor begins on its own. Ask caregiver to schedule surgery as close as possible to due date and ask about amniocentesis to verify baby’s lung maturity
    • Labor benefits babies – babies born by scheduled cesarean without experiencing labor are 4sx more likely to develop persistent pulmonary hypertension, a potentially life threatening situation
    • Severe complications, including breathing difficulties, infection and other problems that require admission to NICU 2x as likely for babies born at 37 weeks than babies born at 39 weeks
    • Not waiting for labor to begin for planned cesarean can lead to accidental prematurity of estimated gestational age is wrong. Knowing exact date of conception, having ultrasound scan early in pregnancy that documents gestational age or having baby’s lung maturity verified are ways to better estimate

Natural Cesareans/Slow cesareans – cesareans used to be used in emergencies; doctors have begun doing it more slowly and encouraging immediate skin to skin after delivery. Learn more http://tinyurl.com/la83t2

Prepare cesarean birth plan – even if planning vaginal birth, consider writing. Ask if you can have 2 support people in OR, what will atmosphere be in OR, if you can choose music, staff narrate what’s happening; if they will chat with you to keep you relaxed; will they stop chatting if you request; will staff lower screen or use mirror to see baby’s birth; restrictions on photographing and video recording; partner announce baby’s sex; minimal suctioning of baby’s nose and mouth; skin to skin; newborn exams done where you can see; can baby stay in OR during repair; breastfeeding after birth; internal repair/double layer suturing; non drug options if experience anxiety, trembling or nausea; when can eat after surgery. If answers don’t satisfy you, consider switching to different caregiver or birthplace.

Understand reasons for cesarean – fully understand benefits, risks, alternatives before consenting. If having emergency one, ask why its needed. Can help you accept events of birth

Insist on early, frequent contact with baby – cesarean, narcotics, and high levels of stress may delay breastfeeding and affect breast milk production. More time you spend nestling baby and more frequently you nurse, sooner milk supply increases. Skin to skin also enhances emotional bond.

Develop postpartum plan – plan for extra support you’ll need

Key Points – more than 30% have cesareans in U.S. vaginal birth has fewer overall risks. Consider cesarean only when potential medical benefits outweigh risks. Steps to take to increase chances of vaginal birth. VBAC viable option for many women with prior cesareans; however local hospital may limit access. Preparing a birth plan for cesarean will help you have a positive birth experience

  1. Emotional responses associated with VBAC

 

  1. Newborn illness or loss

Seriously Ill Newborn or Infant Death

Most babies are born healthy and normal. Some born with health problems (congenital problems) or birth defects. Other babies are born dead (stillbirth) or die around the time of birth from genetic abnormalities, birth trauma or infection.

Seriously Ill Newborn – likely that you or partner can spend time with baby, even if he’s in a special care nursery. If baby is transferred, may be able to arrange for an early discharge from your hospital so you can visit your baby. because of special nutritive qualities of colostrum and breastmilk, may want to nourish baby by breastfeeding or bottle feeding expressed milk. Consider keeping a notebook so you can jot down questions as they arise and record the answers as you receive them. Can also keep track of baby’s treatment and progress.

Infant death – if have still birth or baby dies soon after birth, will have to make several tough decisions. If baby dies before labor begins, do you want labor induced? If so, when? Do you want to be awake and participate in the birth? Do you want the support of a doula or someone other than your partner? After birth, do you want to recover in an area that’s separate from other mothers and babies on the postpartum floor or somewhere else in hospital? Do you want an early discharge from hospital? Do you want an autopsy done to help find cause of death? What may make memories more meaningful? May want religious ceremony such as baptism. May want to photograph, have footprints taken, obtain lock of hair etc.

Coping with a seriously ill newborn or infant death – appendix c has list of resources. Write a record of birth experience. Consider talking to counselor, therapist, hospital chaplain or spiritual leader.

 

  1. Grief process
  1. Helping parents acknowledge and express feelings

 

  1. Five components of caring

 

  1. Other references for reading

ICEA Position Paper on Induction

Spontaneous, physiologic labor provides benefits to babies and mothers. Induction of labor is a process utilizing various chemical and mechanical methods to initiate uterine contractions before onset of labor. Augmentation of labor initiated when labor has either slowed, contractions are hypotonic or labor progress has stopped.

Use – <10% in 1990 to >22% in 2006. Some rates 44%. ACOG – induction indicated when benefits outweigh risks: gestation or chronic hypertension, preeclampsia, eclampsia, diabetes, PROM, severe fetal growth restriction and post-term pregnancy.

Readiness for Induction: Bishop Score – 1964 Bishop developed pelvic scoring system to predict inducibility by evaluating position of cervix, the cervical consistency, dilation, effacement and station of presenting part. Higher score, more favorable cervix; score 6-7 more successful inductions.

Criteria/Scores 0/1/2/3

  • Dilation (cms): 0/1-2/3-4/5/6
  • Effacement %: 0-30/40-50/60-70/80
  • Station: -3/-2/-1/+1, +2
  • Consistency: firm, med, soft, —
  • Position: posterior, mid, anterior, —

Nulliparous women w prolonged pregnancy – Bishop score predicts need for cesarean better than ultrasonagraphic assessment of cervix.

30% increase in preterm births. More pregnant women electing to induce before term and putting babies at risk for significant health issues:

  • Greater chance of dying early
  • More likely to need care in NICU
  • Problems breathing, including needing ventilator
  • Problems feeding, including coordinating sucking and swallowing
  • Increased need for special educational interventions later in life

Indications for Induction – ACOG against elective induction before 39 weeks. Early Deliveries Without Medication Indications – Just Say No. Clinical indications include:

  • Aburptio placentae
  • Chorioamnionitis
  • Fetal demise
  • Gestational hypertension
  • Preeclampsia, eclampsia
  • PROM
  • Postterm pregnancy
  • Maternal medical conditions (diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)
  • Fetal compromise (severe fetal growth restriction, isoimmunization, oligohydramnios)

Contraindications include:

  • Vasa previa or complete placenta previa
  • Transverse fetal lie
  • Umbilical cord prolapse
  • Previous classical cesarean
  • Active genital herpes infection
  • Previous myomectomy entering endometrial cavity

Methods of Induction – non-pharmacologic alternative approaches for cervical ripening and inducing labor can be safe, less-invasive and more cost-effective: acupuncture, sex, nipple stimulation, herbal preps, evening primrose oil, castor oil. Effectiveness less documented. May require longer period to ripen cervix and initiate labor.

Pharmacologic or mechanical induction include: membrane stripping, Foley Balloon Catheter or laminaria tents, cervical ripening agents, Pitocin/Syntocinon, Misoprostol/Cytotec, and AROM via amniohook (amniotomy). Combo of Foley Balloon and misoprostol resulted in shorter induction to delivery time when compared w misoprostol alone without increasing complications. Tachysystole, non reassuring FHR and newborn umbilical cord arterial blood ph<7.1 significantly lower w transvaginal balloon that w dinoprostone vaginal insert.

AROM – lack of evidence for amniotomy being introuduced routinely. Early AROM after misoprostol associated w higher successful vaginal delivery, shorter labor and better neonatal outcome.

Lack of evidence for membrane stripping.

Amniotomy – lack of efficacy of breaking amniotic sac, increased pain of labor w onset of maternal affection immediately after birth as many felt birthing process interrupted.

Complications of Induction – associated w higher risk of PPH than spontaneous labor. In multiparous women, risk of cesarean increases w previous preterm delivery, short maternal height and limited dilation at start of induction. Careful titration of oxytocin necessary to avoid uterine tachysystole (may be reduced by removal of induction agent).

Induction labor associated w shorter duration breastfeeding.

Increase in maternal/neonatal infections w laminaria and other hygroscopic dilators. Foley catheters also can cause significant vaginal bleeding in women w low-lying placenta.

Can result in NICU admission and can increase length of hospital stay and overall cost of care. Elective induction, esp in 1st time moms, frequently results in c-section which exposes moms to risks of surgery, requires longer recovery and affects choices, outcomes and costs in future pregnancies.

Inform couples of other medical interventions such as IV infusion, BP monitoring, rupture of membranes and risk for possible cesarean. Teach benefits/risks.

ICEA Position Paper on Episiotomy

WHO – episiotomy should not be a routine procedure bc there is no evidence that it decreases perineal damage and associated concerns.

One of most common surgical operations in obstetrics; an incision of pudenda (external tissue). Perineotomy is incision of perineum (internal tissue). Used interchangeable. Incision may be made in midline (straight down toward rectum) or may begin in midline but be directed downward and then laterally away from rectum (mediolateral).

Measured in degrees – most common 2nd degree (midway bw vagina and anus) and least common 4th degree (extending through rectum, called episiorectoprotomy). 1st degree involves skin layer only; 2nd degree involves skin and muscle; 3rd degree involves skin, muscle and rectal sphincter and 4th degree involves skin, muscle, rectal sphincter and anal wall.

Factors Influencing the Use of Episiotomy

First described by a Scottish midwife in the 1740s, episiotomies were not widely used until the mid1900s. US obstetricians made the case that childbirth was a pathological process and this small incision would speed labor, decrease trauma and allow the perineum to be restored. Joseph DeLee, the best known early proponent of episiotomy, admitted he lacked evidence to support his recommendation and no further evidence emerged for many years. It enabled the chasm between the medical model of birth and the physiologic model of birth to widen.

Episiotomy does allow for a more rapid and predictable second stage, and so it fit into the assembly-line hospital model of childbirth. It also was reported to reduce trauma to the fetal head, a fact later put into question.

Historically, episiotomy has been indicated in circumstances such as abnormal labor progression, nonreassuring fetal heart rate pattern, vacuum- or forceps assisted vaginal delivery, and shoulder dystocia. It also was believed to hasten the second stage of labor and reduce the risk of spontaneous perineal tearing, subsequent pelvic floor dysfunction, urinary and fecal incontinence, and sexual dysfunction.

ACOG Statement – recent studies show that common indications for episiotomy were based on limited data. Underestimation of potential adverse consequences associated with the procedure, including extension to a third- or fourth-degree tear, anal sphincter dysfunction, and painful sex.

Data suggest that women who have an episiotomy do not have significantly improved labor, delivery, and recovery compared with those who do not have one. Without sufficient data to develop evidence-based criteria for performing episiotomies, clinical judgment remains the best guide to determine when its use is warranted, according to ACOG.

Important to the discussion of episiotomy is perineal massage. Perineal massage is the practice of massaging a pregnant woman’s perineum around the vagina before birth and during the birthing process. The intention is to attempt to prevent tearing of the perineum during birth, the need for an episiotomy or an instrument (forceps or vacuum extraction) delivery. Perineal massage decreases the rate of episiotomies and lacerations as well as the size of episiotomies. A lubricant such as KY Jelly, Vitamin E oil or Almond Oil may be used. Research has shown that perineal massage is associated with a decrease in perineal trauma, prevention of tears and size and rate of episiotomy and lacerations.

Implications for Practice

Childbirth educators have a mandate to present evidence-based information, including that of episiotomy. While episiotomy rates continue to be high and variable within country, state/province, city and even within provider group, numerous medical journals have provided evidence that routine use of episiotomy should be abandoned and episiotomy rates of >30% do not seem justified. While US rates dropped from 1980 (64/100 vaginal deliveries) to 2006 (16.0/100 vaginal deliveries), rates still are extremely variable.

Educators can impact the hegemony of the medical model by actively promoting gravity position/upright positions for the second stage of labor; encourage informed decision making regarding the use of interventions that restrict movement or add to the risk of obstetric anal sphincter injury, teaching physiologic pushing and breathing while discouraging prolonged breath-holding or “purple pushing” and advocating for emotional support and effective communication by all whom attend the labor and birth.

Additionally, educators may wish to establish a foundation for teaching about episiotomies by creating a database of journal articles with the evidence-based information. Evidence showing the benefits to mothers of restrictive episiotomy policies (less severe perineal trauma, less posterior perineal trauma, and fewer healing complications and quoting professional bodies who have issued statements addressing routine episiotomy may be useful to support this teaching. At the same time, information showing that episiotomy at the first vaginal birth significantly and independently increases the risk of repeated episiotomy and spontaneous tears in subsequent delivery.

Studies imply that rates of intervention in labor and birth (including episiotomy) are not always evidence-based but may be influenced by a variety of other factors. The “other factors” include the physicians’ desire to expedite labor as well as their favorable view of episiotomy. Some physicians felt the evidence did not support the guidelines, some felt the recommendations were like a ‘cookbook’ or reduced physician autonomy, or did not apply to their patient population.

Childbirth educators are in a unique position to promote physiologic birthing with fewer interventions, including episiotomy. Through the use of a variety of teaching media, educators can take the lead on disseminating information to both parents and professionals about the latest research involving episiotomy.

ICEA Position Paper on Cesarean Childbirth

Cesarean childbirth, a surgical procedure for delivery of a child(ren) through mother’s abdomen, can be a life-saving operation. Present benefits/risks in objective and evidence based manner. ICEA joins w CIMS in concern regarding rising rates worldwide.

Cesarean section is most common major surgical procedure in U.S. Poses short and long term health risks to mothers and infants, and a scarred uterus poses risks to all future pregnancies and deliveries. CIMS recommends reserving for situations when potential benefits clearly outweigh potential harms. Rate can safely be <15% and 11% or less in low risk women giving birth for first time, yet is >30%. When rates >15%, outcomes for moms/babies worsen and increasing #s of scheduled cesareans are contributing to rising # of late-preterm births.

Rates rising for all women in U.S. regardless of medical condition, age, race or gestational age. # of 1st cesareans performed w out medical indication increase and no evidence supports that these represent maternal request. >70% can birth vaginally (VBAC), but almost all women have repeat operation because most doctors and many hospitals refuse to allow VBAC.

Health outcomes after a cesarean may be worse bc medical problems may lead to surgery.

Potential Harms to Mother:

  • Accidental surgical cuts to internal organs
  • Major infection
  • Emergency hysterectomy (bc of uncontrollable bleeding)
  • Complications from anesthesia
  • Deep venous clots that can travel to the lungs (pulmonary embolism) and brain (stroke)
  • Admission to intensive care
  • Readmission to hospital for complications related to surgery
  • Pain that may last 6 months+ after delivery (more women report problems w pain from cesarean incision that pain in genital area after vaginal birth)
  • Adhesions, thick internal scar tissues that may cause future chronic pain, in rare cases a twisted bowel and can complicate future abdominal or pelvic surgeries
  • Endometriosis (cells from uterine lining that grow outside womb) causing pain, bleeding, or both severe enough to require major surgery to remove abnormal cells
  • Appendicitis, stroke or gallstones in ensuing year. Gall bladder problems and stroke may be bc high weight women and women w high bp are more likely to have cesareans
  • Negative psychological consequences: poor birth experience, overall impaired mental health and or self esteem, feelings of being overwhelmed, frightened or helpless during birth, sense of loss, grief, personal failure, acute trauma symptoms, posttraumatic stress and clinical depression
  • Death

Potential Harms to Baby

  • Accidental surgical cuts, sometimes severe enough to require suturing
  • Being born late-preterm (34-36 wks) as a result of scheduled surgery
  • Complications from prematurity, including difficulties w respiration, digestion, liver function, jaundice, dehydration, infection, feeding and regulating blood sugar levels and body temp. Late-preterm babies also have more immature brains, and they are more likely to have learning and behavior problems at school age.
  • Respiratory complications, sometimes severe enough to require admission to a special care nursery, even in infants born at early term (37-39 wks). Scheduling surgery after 39 weeks minimizes but does not eliminate risk.
  • Readmission to hospital. Childhood development of asthma, sensitivity to allergens, or Type 1 diabetes
  • Death in first 28 days after birth.

Potential Harms to Maternal Attachment and Breastfeeding – failure to breastfeed has adverse health consequences for mothers and babies. Breastfeeding helps protect moms against postpartum depression, Type 2 diabetes, high bp, heart disease, ovarian and pre-menopausal breast cancer and osteoporosis later in life. Breastfeeding helps protect babies against ear infections, stomach infections, severe respiratory infections, allergies, asthma, obesity, Type 1&2 diabetes, childhood leukemia, SIDS and necrotizing enterocolitis (severe, life-threatening intestinal infection).

  • Women w unplanned cesareans more likely to have difficulties forming attachment to babies
  • Women w cesareans less likely to have infants w them skin to skin after delivery. Babies who have skin-to-skin interact more w moms, stay warmer and cry less. When skin-to-skin, babies more likely to be breastfed early and well, and to be breastfed for longer. May also be more likely to have a good early relationship w their moms.
  • Women less likely to breastfeed

Potential Harms to Future Pregnancies – w prior cesarean, women and babies more likely to experience serious complications during subsequent pregnancy and birth regardless of whether they plan repeat cesarean or vaginal birth. Likelihood of serious complications increase w each addtl operation. Compared w prior vaginal birth, prior cesarean puts women at increased risk of:

  • Uterine scar rupture, planning repeat cesarean reduces excess risk, but not completely protective
  • Infertility, either voluntary or involuntary
  • Cesarean scar ectopic pregnancy (implantation w/in cesarean scar), a condition that is life threatening to mother and always fatal for embryo
  • Placenta previa (placenta covers cervix, opening to womb), placental abruption (placenta detaches partially or completely before birth) and placenta accrete (placenta grows into uterine muscle and sometimes through uterus, invading other organs), all of which increase risk for severe hemorrhage and are potentially life threatening complications for mom and baby
  • Emergency hysterectomy
  • Preterm birth and low birth weight
  • Baby w congenital malformations or CNS injury due to poorly functioning placenta
  • Stillbirth

Cesarean Surgery and Pelvic Floor Dysfunction – cesarean proponents claim that cesarean will prevent pelvic floor dysfunction, but it offers little or no protection once healing is complete and no protection in later life. Risk-free measures such as engaging in exercises to strengthen pelvic floor or losing weight can often improve or relieve stress urinary incontinence (loss of urine w pressure on the pelvic floor such as w exercise, laughing, sneezing or coughing):

  • Cesarean does not protect against sexual problems, gas or stool incontinence or urge urinary incontinence (loss of urine after sudden need to void)
  • Cesarean doesn’t protect against severe stress urinary incontinence. As many as 1 more women in 6 having vaginal birth may experience stress urinary incontinence of some degree, mostly minor, at 6 months or more after birth
  • Perhaps 1 more woman in 20 having vaginal birth will experience symptomatic pelvic floor prolapse (muscle weakness causes internal organs to sag downwards). W 3+ vaginal births, this # may be as high as 1 more women in 10. Many other factors, including smoking, hysterectomy, hormone replacement therapy, constipation, irritable bowel syndrome and UTI also associated w pelvic floor prolapse

Cesarean Section, Care Providers and Place of Birth – to reduce risk of cesarean, seek providers w low rates (15% or less) and those that support VBAC. Can access data from state health departments, www.thebirthsurvey.com, or list of hospitals that do/don’t support VBAC at http://icanonline.org/vacban-info

Midwifery care or birth center can also lower risk. Having a doula reduces risk.

ICEA Teaching Idea Sheet: Presenting Unexpected Outcomes

  • Very few people experience the ultimate dream – pregnancy, birth and baby of their expectations
  • Prospective parents are adults who deserve to be told real story; don’t need to be protected
  • Range of outcomes: long labor, unexpected meds, baby born too early, boy instead of expected girl, sick baby who goes to NICU – have info, resources
  • Integrate into sessions rather that isolate to onetime discussion. People will have fears over time; remind self that fears while pregnant is very common
  • During class intros, say all topics open for discussion including fears that might include a less than perfect pregnancy, labor or birth.
  • Ask parents to write on a card a concern/anxiety they have. On other side, write nightmare scenario. Ask to discuss w partner and tell them to address at least 2 things they could do in each case to have control of situation. Collect cards, no names. Can bring some up. Have resources.
  • Small groups or w partners – discuss journey that brought them here. Surprise pregnancy, trying for long time, assisted reproduction or previous miscarriages. How much control have you had so far? How much do you think you will have or want during pregnancy and birth. How much control and fulfillment of dreams is realistic?
  • Unexpected outcome cards for activity in which partners design ideal birth by laying out cards w preferred outcome facing up, while situation on opposite cared is undesired. Ex: epidural vs no epidural. Discuss feelings of both sides. Healthy mom and baby vs blank
  • Share down syndromes association, NICU info, articles on desired sex babies, postpartum depression, infant loss etc

About The Author

Jessica