• Preterm labor
• Post-term pregnancy
• Dystocia
• Abnormal labor patterns
• Obstetric emergencies (shoulder dystocia, prolapsed cord, rupture of uterus, amniotic fluid embolism)

Cervical changes and uterine contractions occuring at 20-37 weeks of GA

• Effacement ≥ 80%
• Cervical dilation ≥ 2 cm
• Regular uterine contractions

Birth that occurs before the completion of 37 weeks GA

• Very preterm birth: <32 weeks
• Later preterm/ near term: 33-37 weeks

• Mom underweight or obese
• Dehydration
• Uterine or cervical anomaly
• Hx of uterine or cervical surgery
• Condition causing uterine overdistention (twins)
• Chronic illness
• Infection (esp. UTI)

• LBW:
• < 2500 g
• Preterm or term baby
• VLBW:
• <1500 g
• Preterm usually, can be term

• Fetal fibronectins 
• Salivary estriol 
• Endocervical length

• Cervical swab
• Glycoproteins produced during early fetal life, appear in cervical canal early in pregnancy
• Appearance b/w 24-34 weeks may predict preterm labor !

• Tests mom's saliva
• Type of estrogen made by the fetus that increases a few weeks before labor
• Increases earlier in preterm labor !

• Uterine contractions (<10 min apart for 1 hr+)
• Lower abdominal cramps (maybe w/ diarrhea)
• Dull, intermittent low back pain
• Menstrual-like cramps
• Pelvic pressure or heaviness
• Urinary frequency
• ROM
• Spotting

• Mostly avoiding precipitating factors:
• Sexual intercourse, riding long distances, carrying heavy loads, standing >50% of the time, climbing stairs, etc.

• Bone demineralization
• Weight loss
• Muscle wasting and weakness
• Psychologically: depression, isolation, boredom, increased stress
• Effects on support system (other children, etc.)

Suppress uterine activity and give time for glucocorticoids to accelerate fetal lung maturity

• Indomethecin (NSAID)
• Nifedipine (CA channel blocker)
• Magnesium sulfate-- be aware of levels !!
• Terbutaune (adrenergic agonist)
• Can cause pulmonary edema--> monitor !!

• PIH or eclampsia
• Active vaginal bleeding
• Intrauterine infection (chorioamnionitis)
• Cardiac disease
• Dilaiton > 6 cm
• Condition that contraindicates continuation of pregnancy

• Estimated GA >34 weeks 
• Fetal death
• Lethal fetal anomaly 
• Acute fetal distress
• IUGR

• Explain purpose and side effects
• Side-lying
• Monitor vitals, I&O, S/S of adverse reactions
• Limit fluids to 1500-2500 ml/day (esp. on beta adrenergic of mg sulfate d/t risk of pulm. edema)
• Psychosocial support, comfort measures, relaxation techniques

• Betamethasone given IM to mom if in labor from 24-34 wks GA (enhances fetal lung maturity)
• Stimulates release of enzymes that increases surfactant 
• Also reduces intraventricular hemorrhage (IVH) in premies
• Do L/S ratio to verify maturity first

• Rupture of the amniotic sac and leakage of fluid at least 1 hr before onset of labor
• Infection risk rises dramatically 18-24 hours after ROM if baby isn't delivered yet !

Preterm PROM (PPROM)

Def. and Complication

• ROM before 37 weeks GA
• Occurs in up to 25% of preterm labor
• Most common complication:
• Infection !
• Chorioamnionitis (intraamniotic infection)
• Group B Strep-- check status ! 

• Strict sterility in vaginal exams
• Use nitrazine paper or fern test to see if discharge is amniotic fluid or urine (may need to bear down)
• Frequent BPPs (fetal status and AFV)
• Kick counts daily
• Prophylactic antibiotics
• Watch for infection !
• Glucocorticoids if no chorioamnionitis !

Pregnancy that extends beyond end of 42 wks GA

aka Postdate Pregnancy

 Often b/c of excessively large infant (macrosomic)

• Probably labor induction
• Instrumental or surgical birth more likely
• If infant macrosomic:
• Dysfunctional labor 
• Birth canal trauma

• Prolonged labor
• Shoulder dystocia
• Birth trauma
• Asphyxia from macrosomia
• Meconium aspiration
• Oligohydramnios w/ cord compression
• Compromising effects of fetus d/t aging placenta

• Induction of labor at 41-42 weeks
• May allow pregnancy to progress up to 43 weeks (if assessments are normal)
• Differs from place to place !

Long, difficult, or abnormal labor

Primary cause for cesarean births

1. Powers: ineffective contractions d/t dysfunctional labor
2. Passageway: alterations in pelvic structure
3. Passenger: fetal causes
4. Position: position of mom
5. Psychological response: lack of support

• Abnormal uterine contractions preventing normal progress of:
• Cervical dilation, effacement, descent
• Most common cause of dystocia ! 
• Types:
• Hypertonic uterine dysfunction
• Hypotonic uterine dysfunction

• Painful, frequent, uncoordinated contractions
• Ineffective dilation or effacement
• Uterus may not relax completely b/w contractions
• Mom exhausted, anxious, may lose control d/t intense pain and lack of progress
• Often anxious, first-time moms in latent phase

• Therapeutic rest !
• Warm bath or shower
• Analgesics (inhibit contractions, reduce pain, and encourage sleep)
• Many women wake up in active labor after 4-6 hours of sleep !

• Usually in active stage after normal progress here
• Contractions are weak or stop
• Uterus is easily indented (even at peak contraction)
• Contractions can't promote effacement or dilation
• Mom may be exhausted

• Cephalopelvic Disproportion (CPD)
• Malpositions
• Overdistention of uterus (e.g. twins)

• Do ultrasound to rule out CPD
• Asses for mal-positions and fetal/maternal well-being
• If findings are normal:
• Ambulate, hydrotherapy
• Strip or rupture membranes
• Nipple stimulation
• Pitocin to augment labor progress

• Obstruction of the birth passage by an anatomic abnormality other than that of bony pelvis
• Placenta previa
• Uterine fibroids (lower uterine segment)
• Ovarian tumors
• Full bladder or rectum
• Cervical edema
• STDs

• Fetal anomalies
• Excessive size
• Malposition
• Malpresentation
• Multifetal pregnancy

• Neonatal asphyxia
• Fetal injuries or fractures
• Maternal vaginal lacerations
• Fetal anomalies (gross ascites, large tumors, open NTDs)
• Fetus may be unable to descend

Fetus can't fit through maternal pelvis

Fetus is too big or pelvis is too small !

Often causes fetus to remian high in pelvis and not descend 

ROP or LOP is bad !

Mom will complain of severe back pain

• Hormones and neurotransmitters released
• In response to:
• Stress, severe pain, excess anxiety, absence of a support person
• Results in:
• Reduces contractions, inhibits dilation, prolongs labor, increases perception of pain

• Multiparity
• Large pelvis
• Previous precipitous labor
• Small fetus in favorable position
• Strong contractions
• Uterine hyperstimulation from excess Pitocin

• Loss of coping ability
• Lacerations (cervix, vagina, or perineum)
• PP uterine atony
• Hemorrhage from undetected lacerations or atony
• Fetal stress or hypoxia (d/t intense contractions)
• Fetal cerebral trauma (d/t rapid descent)
• Fetal pneumothorax (d/t rapid descent)

• Frequent monitoring of mom, fetus, and progress
• Prepare birth supplies on admission !
• Constantly with mom (if possible)
• Avoid uterine hyperstimulation
• Stop Pitocin PRN
• Side-lying position
• Supplemental O2 PRN
• Continuous EM
• Administer tocolytic as ordered

Turning the fetus from one presentation to another

Done externally or internally

Painful !

Done if baby is breeched or shoulder presentation after 37 weeks GA

• Use ultrasound before procedure to:
• Determine fetal position, locate cord, rule out placenta previa, evaluate pelvis, assess AFV, assess fetal age, detect anomalies
• NST ot confirm well-being
• During procedure: FHR, mom's VS, and comfort
• After procedure: monitor vitals, uterine activity, FHR, assess for bleeding, give RhoGam PRN

• Done if:
• Pelvis is questionable size or shape
• Fetus in abnormal presentation
• Mom wants a VBAC
• Observe mom and fetus for a reasonable period (4-6 hrs of active labor) to assess safety of vaginal birth !
• Vitals, contractions, labor progress
• FHR and patterns

• Chemical or mechnical initiation of contractions before their spontaneous onset
• Most common methods in US:
• IV Pitocin
• Amniotomy (AROM)

• Rating system used to determine if the cervix is favorable for induction (aka inducible)
• Inducible if score is:
• ≥ 9 for nulliparas
• ≥ 5 for multiparas
• If not favorable, need cervical ripening interventions

• Lower dosages of Pitocin needed during induction
• Shorter induction times
• Possible elimination of need for Pitocin (may begin labor)

• Prostaglandin E₂ gel
• Use before induction to soften and thin the cervix
• Cervidil
• Cytotec (misoprostol)

• Artificial rupture of membranes (AROM)
• Can decrease length of labor by 2 hrs
• Most effective if pitocin is used along with amniotomy 

• Induce labor when condition of cervix is favorable
• Augment labor if progress begins to slow

• Presenting part should be engaged beforehand
• Amnihook used to rupture membranes
• Assess:
• Color, odor, and consistency of fluids
• FHR (before, during, immediately after)
• Temperature (2 hrs after)
• Provide comfort measures

• Fetal issues:
• CPD, prolapsed cord, transverse lie, or non-reassuring FHR
• Maternal issues:
• Placenta previa, hx of uterine surgery, or hx of classic uterine incision

• Turn mom onto her side
• Increase IV fluid rate
• Administer O2 @ 8-10 L/min
• Notify physician or midwife
• Administer tocolytic agents per order
• Continue monitoring FHR & uterine activity
• Document responses to interventions

• Management of hypotonic uterine dysfunction
• Slow labor process (prolonged active phase)

• Oxytocin/ Pitocin infusion
• Amniotomy
• Nipple stimulation
• Ambulation
• Position changes
• Hydration
• Hydrotherapy

• Fetal distress
• Abnormal presentation
• Arrest of rotation

(same for vacuum-assisted birth)

• No CPD
• Cervix fully dilated
• ROM, bladder empty
• Engaged presenting part
• Vertex presentation desired

• Neonatal acchymosis (bruise) or edema at forcep site
• Facial lacerations
• Caput succedaneum or cephalohematoma (w/ resulting hyperbilirubinemia)
• Transient facial paralysis
• Cerebral hemorrhage

• Vaginal or perineal lacerations
• Infection (d/t lacerations)
• Increased bleeding
• Bruising 
• Perineal edema
• Extension of episiotomy to 3^rd or 4^th degree tear
• Risk for fetal incontinence

• Vacuum cup is applied to the fetal head
• Negative pressure used to assist delivery of the head
• Indications similar to forceps use

• Vertex presentation
• ROM
• No CPD

• Cephalhematoma
• Scalp lacerations
• Subdural hematoma

• Perineal, vaginal, or cervical lacerations
• Soft-tissue hematomas

• Birth through a transabdominal incision of the uterus
• Planned (scheduled) or unplanned (emergency)
• Anesthesia used:
• Spinal
• Epidural
• General (only in emergencies)

• Vertical incision
• Rarely done now
• Higher incidence of infection and uterine rupture in future pregnancies
• VBAC is contraindicated in future
• Used if rapid birth is needed

• Vertical or transverse incision
• Associated with less blood loss

• Vaginal birth after cesarean section
• Can be attempted if reason for first C-section is non-recurring, such as:
• Dystocia
• Breech presentation
• Nonreassuring fetal status

• Rare but require immediate intervention to preserve the health or life of the mom or fetus
• Shoulder dystocia
• Prolapsed cord
• Rupture of the uterus
• Amniotic fluid embolism

• When the head is born but anterior shoulder can't pass under the pubic arch
• Mom must be positioned in specific ways to deliver rest of fetus

• Asphyxia
• Brachial plexus damage
• Fractured clavicle
• Collapsed lung

• Excessive blood loss d/t:
• Uterine atony or rupture
• Lacerations
• Extension of episiotomy
• Endometritis

• Macrosomic NB (>4500 g)
• Contracted pelvis
• Gestational diabetes
• "Turtle sign" (appearance & retraction of fetal head)

• Occurs when the cord lies below the presenting part of the fetus
• Cord is compressed when contractions occur

• Long cord (longer than 100 cm)
• Malpresentation (breech)
• Transverse lie
• Unengaged presenting part

• Relieve pressure w/ hand in vagina (sterile glove)
• Knee-chest position
• Monitor FHR
• Prepare for emergency C-section
• Provide info and emotional support (mom and family)
• If cord protruding--> place warmed moist cloth on to prevet drying, do not handle cord

Bed rest after ROM until engagement confirmed (may occur after SROM)

Nurse may notice cord at introitus

Mom may say she feels something in her vagina

• Rare, serious OB injury
• 1 of 1500-2000 births
• Can lead to fatal blood loss for mom and baby
• C-section will be performed and possibly hysterectomy (if bleeding is severe)

• Separation of scar during VBAC from previous classic C-section
• Uterine trauma (accidents, surgery)
• Congenital uterine anomaly

• Complaints of pain (esp. if unanaesthetized)
• Fetal distress
• Easier to feel fetal parts through abdominal wall

• Hemorrhage
• Hysterectomy
• NB death or neurological complications

• Intense spontaneous contractions
• Labor stimulation (oxytocin release)
• Over-distended uterus
• Malpresentation (external or internal version)
• Difficult forceps-assisted birth

• Amniotic fluid containing particles of debris enters mom's circulation and obstructs pulmonary vessels
• Debris = vernix, hair, skin cells, meconium
• Results in respiratory distress and circulatory collapse

• Large bore IV
• CPR
• Prepare for C-section
• Administer blood 

• Sudden onset respiratory distress
• Acute hemorrhage
• Circulatory collapse
• Hemorrhagic shock
• Coma and maternal death
• Fetal death (if birth isn't immediate)

• Hemorrhage
• Hysterectomy
• NB death or neurological complications

• Counter pressure
• Pelvic rocking
• Positioning:
• Hands & knees
• Squatting
• Side-lying
• Kneeling