Labor and Birth at Risk
• Differentiate between preterm birth and low birth weight.
• Identify the major risk factors associated with spontaneous preterm birth.
• Analyze current interventions to prevent spontaneous preterm birth.
• Discuss the use of tocolytics and antenatal glucocorticoids in preterm labor.
• Evaluate the effects of prescribed bed rest on pregnant women and their families.
• Design a nursing care plan for women with preterm premature rupture of membranes (preterm PROM).
• Summarize the nursing care for women having induction or augmentation of labor, forceps- and vacuum-assisted birth, cesarean birth, and vaginal birth after a cesarean birth.
• Explain the care of a woman with postterm pregnancy.
• Discuss obstetric emergencies and their appropriate management.
anaphylactoid syndrome of pregnancy (ASP)
Rare complication of pregnancy characterized by the sudden, acute onset of hypoxia, hypotension, or cardiac arrest and coagulopathy that can occur either during labor or during birth or immediately after birth; also known as amniotic fluid embolism
Medications administered to the mother for the purpose of accelerating fetal lung maturity when an increased risk exists for preterm birth between 24 and 34 weeks of gestation
Stimulation of ineffective uterine contractions after labor has started spontaneously but is not progressing satisfactorily
Rating system to evaluate inducibility (ripeness) of the cervix; a higher score increases the likelihood of a successful induction of labor
cephalopelvic disproportion (CPD)
Condition in which the infant’s head is of such a shape, size, or position that it cannot pass through the mother’s pelvis, or the maternal pelvis is too small, abnormally shaped, or deformed to allow the passage of a fetus of average size
Inflammatory reaction in fetal membranes to bacteria or viruses in the amniotic fluid, which then become infiltrated with polymorphonuclear leukocytes
Abnormal uterine contractions that prevent normal progress of cervical dilation, effacement, or descent
Prolonged, painful, or otherwise difficult labor caused by various conditions associated with the five factors affecting labor (powers, passage, passenger, maternal position, and maternal emotions)
external cephalic version (ECV)
Turning of the fetus to a vertex presentation by external exertion of pressure on the fetus through the maternal abdomen
Vaginal birth in which forceps (i.e., curved-bladed instruments) are used to assist in the birth of the fetal head
hypertonic uterine dysfunction
Uncoordinated, painful, frequent uterine contractions that do not cause cervical dilation and effacement; primary dysfunctional labor
Weak, ineffective uterine contractions usually occurring in the active phase of labor; often related to cephalopelvic disproportion or malposition of the fetus; secondary uterine inertia
Hormone produced by the posterior pituitary gland that stimulates uterine contractions and the release of milk in the mammary glands (let-down reflex); synthetic oxytocin is a medication that mimics the uterine stimulating action of oxytocin
Rapid or sudden labor lasting less than 3 hours from the onset of uterine contractions to complete birth of the fetus
premature rupture of membranes (PROM)
Rupture of the amniotic sac and leakage of amniotic fluid before the onset of labor at any gestational age
preterm premature rupture of membranes (preterm PROM)
Premature rupture of membranes that occurs before 37 weeks of gestation
Administration of analgesics and implementation of comfort or relaxation measures to decrease pain and induce rest for management of hypertonic uterine dysfunction
Medications used to suppress uterine activity and relax the uterus in cases of hyperstimulation or preterm labor
Period of observation to determine whether a laboring woman is likely to be successful in progressing to a vaginal birth
Birth involving attachment of a vacuum cap to the fetal head (occiput) and application of negative pressure to assist in birth of the fetus
Web Resources
Additional related content can be found on the companion website at 
http://evolve.elsevier.com/Lowdermilk/Maternity/
• Animation: Breech Examination
• Animation: Shoulder Dystocia
• Case Study: Postdate Pregnancy
• Nursing Care Plan: Dysfunctional Labor: Hypotonic Uterine Dysfunction with Protracted Active Phase
• Nursing Care Plan: Preterm Labor
• Spanish Guidelines: Cesarean Birth
• Spanish Guidelines: Induction of Labor
W hen complications arise during labor and birth, the risk of perinatal morbidity and mortality increases. Some complications are anticipated, especially if the woman is identified as high risk during the antepartum period; others are unexpected or unforeseen. A crucial responsibility for nurses is to understand the normal birth process to prevent and detect deviations from normal labor and birth and to implement nursing measures when complications arise. Optimal care of the laboring woman, fetus, and family experiencing complications is possible only when the nurse and other members of the obstetric team use their knowledge and skills in a concerted effort to provide competent and compassionate care. This chapter focuses on the problems of preterm labor and birth, dystocia, postterm pregnancy, and obstetric emergencies.
Preterm Labor and Birth 
Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy. Preterm birth is any birth that occurs before the completion of 37 weeks of gestation (Iams & Romero, 2007). It occurs in approximately 12.8% of all live births, and the rate has been increasing for the last several years. Preterm birth is the major unsolved problem in perinatal medicine today (Iams, Romero, & Creasy, 2009).
Case Study: Preterm LaborApproximately 75% of all preterm births are termed late preterm births because they occur between 34 and 36 weeks of gestation. Although these babies experience significant complications, the great majority of infant deaths and the most serious morbidity occur among the 16% of all preterm infants who are born before 32 weeks of gestation (Iams et al., 2009). See Chapters 18 and 24 for more discussion of problems related to late preterm birth.
Preterm Birth versus Low Birth Weight
Although they have distinctly different meanings, the terms preterm birth or prematurity and low birth weight were often used interchangeably in the past. Preterm birth describes the length of gestation (i.e., less than 37 weeks regardless of the weight of the infant), whereas low birth weight describes only weight at the time of birth (i.e., ≤2500 g). Because birth weight was far easier to determine than gestational age, in many settings and publications, low birth weight was used as a substitute term for preterm birth. Preterm birth, however, is a more dangerous health condition for an infant than low birth weight because a decreased length of time in the uterus correlates with immaturity of body systems. Low birth weight babies can be, but are not necessarily, preterm; low birth weight can be caused by conditions other than preterm birth, such as intrauterine growth restriction (IUGR), a condition of inadequate fetal growth not necessarily correlated with initiation of labor. On the other hand, infants born at a preterm gestation can weigh more than 2500 g at birth. Today, thanks to advances in pregnancy dating, outcomes related to gestational age can be increasingly distinguished from outcomes related to birth weight (Iams et al., 2009).
The incidence of preterm birth in developed countries has increased mainly as a result of more late preterm births and multifetal gestations. An increased use of assisted reproductive technologies has led to the rise in multifetal gestations (Iams et al., 2009). An increasing willingness on the part of health care providers to end the pregnancy when maternal or obstetric conditions threaten the health of mother or fetus after 32 to 34 weeks of gestation also contributes to the rise in preterm births (Iams & Romero, 2007).
Increasingly, preterm births are being divided into two categories, spontaneous and indicated. Spontaneous preterm births occur after an early initiation of the labor process. Conditions such as preterm labor with intact membranes, preterm premature rupture of membranes (preterm PROM), cervical insufficiency, or amnionitis often result in preterm birth. Approximately 75% of all preterm births in the United States are spontaneous (Iams et al., 2009). Box 22-1 lists risk factors for the development of spontaneous preterm birth.
Indicated preterm births, on the other hand, occur as a means to resolve maternal or fetal risk related to continuing the pregnancy. Approximately 25% of all preterm births in the United States are indicated because of medical or obstetric conditions that affect the mother, the fetus, or both. An increase in the number of indicated preterm births accounts for much of the recent rise in late preterm births (Iams et al., 2009). Box 22-2 lists common causes of indicated preterm births.
The remainder of this section deals with spontaneous preterm labor and birth.
Predicting Spontaneous Preterm Labor and Birth
A history of previous preterm birth, multiple gestation, bleeding after the first trimester of pregnancy, and a low maternal body mass index have been shown to be major risk factors for spontaneous preterm birth (Iams & Romero, 2007). Other risk factors include non-Caucasian race (especially African-American), low socioeconomic and educational status, living with chronic stress, smoking, substance abuse, physically demanding working conditions, and periodontal disease (Iams et al., 2009). A recent study found that perceived levels of stress measured at 28 weeks of gestation in African-American women experiencing preterm labor were higher in those who gave birth prematurely than in those whose pregnancies reached term (Gennaro, Shults, & Garry, 2008). In addition, the risk for preterm birth appears to be genetically related. Relatives of women who were born prematurely or gave birth prematurely also have an increased risk for spontaneous preterm birth (Iams et al., 2009).
Many risk scoring systems have been developed in an attempt to determine which women might go into labor prematurely. None of these systems has been very successful, however, because at least 50% of all women who ultimately give birth prematurely have no identifiable risk factors (Iams & Romero, 2007; Iams et al., 2009). Therefore all women should be educated about prematurity not only in early pregnancy, but also in the preconceptional period.
Biochemical markers
Fetal fibronectin has been studied extensively and is currently marketed in the United States as a diagnostic test for preterm labor. Fetal fibronectin is a glycoprotein found in plasma produced during fetal life. The test is performed by collecting fluid from the woman’s cervix and vagina using a swab during a vaginal examination. Fetal fibronectin is normally present in cervical and vaginal fluid early in pregnancy and then again in late pregnancy.
The presence of fetal fibronectin during the late second and early third trimesters of pregnancy may be related to placental inflammation, which is thought to be one cause of spontaneous preterm labor. The presence of fetal fibronectin is not very sensitive as a predictor of preterm birth, however. Before 35 weeks of gestation a positive fetal fibronectin test predicts preterm birth only approximately 25% of the time. The test’s sensitivity may be better earlier in pregnancy. In one study the fetal fibronectin test predicted 65% of preterm births occurring before 28 weeks of gestation when it was performed between 22 and 24 weeks. The test is often used to predict who will not go into preterm labor because preterm birth is very unlikely to occur in women with a negative result. Use of the fetal fibronectin test in women who are at low risk for preterm birth as a screening tool is not recommended (Iams et al., 2009).
Cervical length
Another possible predictor of preterm birth is endocervical length. Changes in cervical length occur before uterine activity; therefore cervical measurement can identify women in whom the labor process has begun. However, because preterm cervical shortening occurs over a period of weeks, neither digital nor ultrasound cervical examination is very sensitive at predicting imminent preterm birth (Iams et al., 2009). Women whose cervical length is more that 30 mm are unlikely to give birth prematurely even if they have symptoms of preterm labor (Iams & Romero, 2007; Iams et al., 2009).
Causes of spontaneous preterm labor and birth
Infection is currently the only factor that has been definitely shown to cause preterm labor. Another proposed cause of preterm labor and birth is bleeding at the site of placental implantation in the uterus in the first or second trimester of pregnancy. The resulting uteroplacental ischemia or hemorrhage at the decidual layer of the placenta may somehow activate the preterm labor process. Intrauterine inflammation is associated with infection, uterine vascular compromise, and decidual hemorrhage, and may contribute to preterm labor. Maternal and fetal stress, uterine overdistention, allergic reaction, and a decrease in progesterone are other factors that may play a part in initiating preterm labor. That preterm labor is caused by multiple pathologic processes that eventually result in uterine contractions, cervical changes, or membrane rupture is becoming increasingly clear (Iams et al., 2009; Romero & Lockwood, 2009).
Two recent research studies suggest that recurrent preterm birth can be prevented in some women by administering prophylactic progesterone supplementation. In one study, women were given vaginal suppositories daily. In the other, women received weekly intramuscular injections of 17-alpha hydroxyprogesterone caproate. In both studies the risk of recurrent preterm birth was reduced by approximately one third. Exactly how progesterone works to prevent recurrent preterm birth is unclear; thus more study is necessary. Another important point to note is that prophylactic supplemental progesterone administration is recommended only for women who have previously given birth prematurely (Meis & Society for Maternal-Fetal Medicine, 2005; Romero & Lockwood, 2009).
Care Management 
Because all pregnant women must be considered at risk for preterm labor, assessment regarding knowledge of this condition begins early in pregnancy and continues throughout the prenatal period. Nursing diagnoses, interventions, and expected outcomes of care will be established for each woman based on her assessment findings (see the Nursing Process box: Preterm Labor and the Nursing Care Plan box: Preterm Labor).
Nursing Care Plan
Preterm Labor
Nursing Diagnosis Deficient knowledge related to the recognition of preterm labor
Expected Outcome Woman and significant other will verbalize the signs and symptoms of preterm labor.
Nursing Interventions/Rationales
• Assess what the partners know about abnormal signs and symptoms during pregnancy to identify areas of deficit.
• Discuss signs and symptoms that serve as warning signs of preterm labor so that the woman or her partner has adequate information to identify problems early.
• Provide written supplemental materials that include a list of warning signs and instructions regarding what to do if any of the listed signs occur so that the couple can reinforce and review learning and act swiftly and appropriately should a sign occur.
• Discuss and demonstrate how to assess and time the contractions to provide needed skills to assess the signs of labor.
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