Chapter 8: Complications During Labour & Birth

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Welcome back to the Deep Dive.

Today we are really buckling up for something that is both incredibly technical and frankly absolutely vital for anyone entering the nursing profession in Canada.

We're taking a very specific, very detailed look at chapter 8 of Lifer's introduction to maternity and pediatric nursing in Canada.

It's a massive topic.

I mean, the title of this chapter really says it all, nursing care of women with complications during labor and birth.

Right.

But I think before we even, you know, open the book, we need to adjust our mindset a little bit.

Oh, how so?

Well, we spend a lot of time in nursing school focusing on the happy path, you know, the spontaneous labor, the unmedicated birth, the perfect golden hour.

The ideal scenario.

Exactly.

But if you look at the stats, especially here in a Canadian context, that perfect path is often the exception, not the rule.

So while this chapter is titled complications, a lot of what we're going to talk about.

Things like induction, C -sections.

Induction, C -sections, instrumental deliveries.

These are just the realities of modern obstetrics.

That's a great point.

We aren't just talking about, you know, rare disasters.

We are talking about the Tuesday morning shift.

Yes.

Whether you're dealing with a low -risk pregnancy that suddenly changes or a high -risk situation from the get -go, the nurse's role is absolutely central.

It's the linchpin.

And our mission for this deep dive is very, very precise.

Okay.

We are going to walk through this chapter exactly as it's written.

We are designing this for the learner,

specifically the nursing student, preparing for exams or clinical rotations in the Canadian healthcare context.

Right.

We aren't adding our own spin.

We are bringing in outside theories.

We are basically translating the clinical concepts from the text into a conversation to help you understand them deeply.

We want to be that voice in your ear helping you review.

So the roadmap for today is pretty extensive.

It is.

We're going to cover induction and augmentation, obstetrical procedures like C -sections and assisted deliveries,

abnormal labor patterns, what the text calls dysfunctional labor.

And then we'll get into special considerations like preterm labor and, finally, the true obstetrical emergencies.

It is a full slate.

Let's start right at the beginning with how labor gets started when it doesn't happen on its own.

Okay.

We need to distinguish between two terms that often get thrown around together but mean different things, induction and augmentation.

Right, because on the chart, they can look similar, usually involving an oxytocin drip.

But the physiological starting point is totally different.

It's the difference between lighting a fire from scratch versus blowing on embers that are already glowing.

It's a huge difference.

That's a great analogy.

So induction of labor is the artificial initiation of labor before it begins naturally.

You are starting the car from a cold stop.

Whereas augmentation implies the process has already started.

Yes.

Maybe she's having some contractions, maybe her water broke, but the engine is stalling.

It's not effective enough to dilate the cervix, so you intervene to stimulate those contractions.

And the text references the SOGC.

There's the Society of Obstetricians and Gynecologists of Canada, and they are very clear on the objective here.

The goal of induction is not just get the baby out.

That's not it.

Right.

The goal is to achieve a successful vaginal birth that is as normal as possible.

That distinction really matters because induction carries risks, right?

If you force the body before it's ready, you could actually increase the likelihood of a C -section.

Significantly.

It's not about rushing.

It's about safety and outcomes.

And timing is critical.

The text emphasizes that induction is generally avoided before 39 weeks gestation, unless there's a compelling medical reason.

Absolutely.

You really want to wait until after 40 weeks if possible.

Because fetal maturity is the priority.

You don't want to induce a baby that isn't actually termed yet just because the calendar says so.

No.

And you need to confirm that the fetus is ready.

The text mentions using a first trimester ultrasound report to assist with dating the pregnancy accurately.

That early scan is the gold standard for dating.

Okay, so now, before a provider decides to induce, they have to assess if the body is actually ready to do this.

And this brings us to a major concept for nursing students.

The BICP score.

If there is one table in this chapter that you should visualize in your mind for an exam, it is table 8 .1.

Right.

The BICP score is used to assess the status of the cervix to determine how it will respond to induction.

Think of it as a pre -flight checklist.

It breaks down five specific components and you score each component from what?

Zero to three.

Zero to three, usual.

I think we should walk through these in detail because students often memorize the numbers but forget what they're actually feeling for during a vaginal exam.

That's the most important part.

Let's do it.

First up, dilation.

This is the obvious one.

How open is the door?

So a score of zero is closed.

Zero centimeter.

Zero centimeters.

A score of three would be around five to six centimeters.

So if she's already dilated, the body is doing some of the work.

Okay.

Second is consistency.

This is the one that takes practice to feel.

Is the cervix firm, medium, or soft?

I always use the facial analogy here.

A firm cervix feels like the tip of your nose.

It's resistant.

That's a score of zero.

That's a soft one.

A soft cervix feels like your lips or your cheek.

It's buttery.

It's pliable.

That gets a higher score, a two.

We want it to be soft because a soft cervix is what opens.

Then there is the length of the cervix.

We measure this in centimeters.

Right.

A long cervix, so greater than four centimeters, gets a zero.

It hasn't started to thin out yet.

Then a short cervix.

A short one, maybe one to two centimeters.

That's a two.

We want it short.

Fourth is cervical effacement, which is related to length, but it's expressed as a percentage of thinning.

Exactly.

So zero to 30 % effaced is a zero score.

80 % effacement is a three.

You're almost there.

And finally, the position of the cervix.

This is so crucial and often overlooked.

Is it posterior, midline, or anterior?

Early in pregnancy, the cervix is tucked way back towards the spine.

That's posterior.

It's hard to reach.

That's a zero.

And as labor gets closer.

As labor approaches, it swings forward to be anterior.

So if you feel it right there, front center, that's a score of two.

The text also mentions station in there as well.

It does.

Where the presenting part is relative to the ischal spines.

So a minus three station is really high up.

That's a score of zero.

A plus one or plus two is low.

That gets you a three.

So you add all these numbers up.

What is the magic number?

What tells us, yes, this induction will likely work?

A score above six.

The text states that a score above six indicates the cervix is ripe or ready for labor induction.

If it's below six.

If it's below six, the cervix is considered unripe.

Hooking that woman up to oxytocin immediately is probably going to fail.

You need to do some work to get it ready first.

The text also mentions a test here, fetal fibronectin.

Yes, FFN.

The presence of increased fetal fibronectin at the cervix is another indicator of readiness.

It sort of acts as a biochemical marker that goes along with that physical bishop score.

Okay.

So we know how to check if they're ready, but why do we do it?

What are the valid medical indications for induction?

The text is pretty specific that convenience isn't one of them.

Oh, absolutely not.

Convenience for the provider or the family is not a valid medical indication.

But there's a small exception, isn't there?

There is a nuance.

The very rapid labor and lives a long distance from the hospital induction might be considered to prevent, you know, a birth on the side of the highway.

That makes sense.

But generally we're looking for a clear medical necessity.

Like gestational hypertension.

Yes, hypertension or preeclampsia.

The cure for preeclampsia is delivery.

Also ruptured membranes without the onset of labor, especially if the mother is group B strep positive.

You don't want the baby sitting in that environment for too long.

No.

Or if there's an infection in the uterus, what we call

chorioamnionitis.

Right.

And then there are other maternal medical problems.

If the mom has diabetes or renal disease that's getting worse, the pregnancy itself might be putting too much strain on her body.

And there can be fetal concerns too.

For sure.

Things like intraterine growth restriction or IUGR,

post -tates pregnancies where the placenta might be failing, or sadly, fetal death.

These are reasons where the risk of continuing the pregnancy is higher than the risk of induction.

On the flip side, we have the contraindications.

When do we say absolutely not we cannot induce?

You generally do not induce if there is placenta previa.

That's where the placenta is covering the cervix, right?

Exactly.

If you induce labor there, you are inducing a massive hemorrhage.

You also don't induce if there is an umbilical cord prolapse or an abnormal fetal lie, like a

footling breach.

An act of herpes.

Yes.

An act of herpes infection in the birth canal is a contraindication because the infant can acquire it during birth, which can be just devastating.

What else?

Also, if there is a pelvic structural deformity or a previous classic vertical C -section incision.

We will definitely talk more about those incisions later, but that vertical one carries a much higher risk of uterine rupture.

A much higher risk, yes.

So let's assume we have a valid reason, and we've checked the Bishop score.

If the cervix isn't ready, or even if we just want to help things along gently,

what are our options?

The text starts with non -pharmacological methods.

These are often called complementary and alternative health modalities or CAHM.

They've been used for centuries.

One method is nipple stimulation.

This is just fascinating physiology.

Stimulating the nipples causes the posterior pituitary gland to secrete natural oxytocin.

So you're basically tricking the body.

You are.

The text suggests techniques like rolling the nipples, using a dry washcloth, or even using a breast pump.

It essentially mimics breastfeeding to get the body to contract.

And then there's the one that usually gets a nervous laugh in prenatal class sexual intercourse.

It's a valid physiological method.

It works on two levels.

First, female orgasm stimulates uterine contractions.

Second, and this is more important for the cervix, male ejaculate contains natural prostaglandins.

So it's a natural cervical ripening agent?

It is.

The text also emphasizes positioning.

Gravity is our friend here.

Walking, sitting, squatting, anything that uses the baby's weight to press on the cervix.

And there's a specific tool mentioned and visualized in figure 8 .1 called the peanut ball.

Oh, the peanut ball.

This has become such a staple in labor and delivery units.

It looks exactly like a peanut shell, a gym ball that's narrowed in the middle.

And how is it used?

It is placed between the woman's legs while she's in bed.

It's particularly helpful for women who have an epidural and are restricted to beds.

So it keeps the pelvis mobile even when the mom isn't?

Exactly.

By opening the knees with that specific shape, it opens up the pelvic diameter to help the baby descend.

Another method mentioned is membrane sweeping.

Right.

This is where the provider manually separates the membranes from the lower uterine segment.

It's uncomfortable, but it's thought to release prostaglandins and get things going.

Okay.

Now moving to the medical side,

pharmacological and mechanical methods.

If that Bishop score is low, say a two or three, we need cervical ripening.

How do we do that chemically?

We use prostaglandins.

The text details two main types.

First, prostaglandin E2, also known as dinoprostone or servital.

This is usually a vaginal insert or a gel.

And the nurse's role here is very specific regarding monitoring.

Very specific.

You need to explain the procedure to the patient.

You monitor the fetal heart rate, the FHR, for about 20 minutes beforehand to get a good baseline.

You have to know the baby is happy before you start.

And after insertion?

After insertion, the patient must remain supine,

usually with a wedge under one hip to prevent hypotension for one to two hours.

You're monitoring for contractions in FHR to make sure the drug doesn't work too well?

Exactly.

You're watching for any signs of hyperstimulation.

The other type is prostaglandin E1 or mesoprostol.

Right.

The text notes this is technically an off -label use.

It's designed for peptic ulcers, but it's highly effective for ripening.

However, it's associated with a higher risk of tachycystal.

We'll define that in a minute, but it means too many contractions.

Yeah, too many.

Here is a massive safety alert for the students listening.

Who should not get prostaglandins?

This is so important.

Women with a previous C -section or other uterine surgery.

The risk of uterine rupture is just too high.

If you ripen a scarred cervix with chemicals, you might cause the scar to give way.

And there's a caution for women with asthma too.

Yes.

Women with asthma should be treated with caution because prostaglandins are bronchodilators and could paradoxically worsen their condition or interact with their physiology in some negative way depending on the specific preparation.

Then we have mechanical methods.

How do we wipe in the cervix without drugs?

We can use hydroscopic dilators like laminaria.

These are actually made from seaweed stems.

Wow.

They absorb fluid from the tissues and swell, physically stretching the cervix open.

Or you can use a trans -cervical balloon dilator.

Which is basically a Foley catheter.

It's a Foley catheter.

You insert it through the cervix, inflate it with saline, and then apply some gentle traction.

It puts mechanical pressure on the internal os.

Once the cervix is ripe or if labor needs a kickstart, we might see an amniotomy.

This is arom artificial rupture of membranes.

This is where the provider uses a sterile sharp instrument.

It often looks like a little crochet hook to break the water.

And what's the goal with that?

It stimulates prostaglandin secretion and allows the fetal head to apply more direct pressure to the cervix.

But it's not without risk.

The text lists three major complications.

Which are?

Prolapse of the umbilical cord, infection, and placental abruption.

Prolapse sounds terrifying and we will cover the emergency response to it later.

But what does the nurse do in the moment of the procedure?

The nursing care is very specific.

Immediately after the rupture, you check the fetal heart rate for at least one full minute.

Why a full minute?

Why not just a quick check?

Because you're looking for decelerations.

If the cord washed down with the fluid and is now being compressed, you will see that heart rate drop.

You need to catch it instantly.

A quick check might miss it.

And you're also assessing the fluid.

Yes.

Color matters.

Clear is good.

Green means there's meconium.

The baby has pooped in utero, which can indicate distress or just post maturity.

And what about cloudy or smelly fluid?

Cloudy or melodorous suggests infection.

And because that protective seal is now broken, you have to monitor the mother's temperature every two hours.

If it hits 38 degrees Celsius, that suggests chorioamnionitis is developing.

Okay, let's talk about the big gun for induction, oxytocin or synthosinon, as it's often called.

This is the most common method, but listen carefully.

It is a high alert medication.

It must be administered by an RN with specific training.

And it's always given as a secondary IV line, a piggyback on a pump.

Always.

Why a secondary line?

Why not just put it in the main bag?

Because if there is a problem, you need to be able to stop the oxytocin immediately without losing your main IV access for fluids or other emergency drugs.

That makes sense.

You connect it to the port closest to the patient so there isn't a lot of drug left in the tubing when you shut it off.

And the process is to start low and titrate up slowly.

The complication we're watching for is tachycystole.

You mentioned this earlier.

What is the strict definition from the text?

Tachycystole is defined as more than five contractions in a 10 -minute window or contractions lasting longer than 90 seconds or less than 60 seconds of rest between them.

Why is that lack of rest so dangerous for the pady?

Because the placenta refills with oxygenated blood between contractions.

During a contraction, blood flow to the pady is restricted.

If there's no rest period, the fetus is essentially holding his breath indefinitely.

It causes fetal distress and hypoxia.

Okay, so safety alert.

I'm the nurse.

I see tachycystole on the strip where the fetal heart rate is dropping.

What is the drill?

What do I do first?

You act immediately.

First, stop or decrease the oxytocin.

Turn it off.

That's step one.

Step two.

Second, reposition the woman.

Get her off her back, usually to a lateral side lying position to improve blood flow to the placenta.

Okay, so stop the drip, turn her on her side.

Then what?

Third, give oxygen 8 to 10 liters per minute via face mask.

Fourth, you notify the provider.

You might also administer a 2 -glytic like nitroglycerin to relax the uterus if it won't stop cramping.

That sequence, stop, turn, oxygen notify is absolutely crucial for students to memorize.

It saves lives.

It really does.

And one other thing to monitor vital signs.

Oxytocin can cause water intoxication too, a kind of fluid retention.

So you have to keep a close eye on her input and output.

Okay, let's shift gears to obstetrical procedures.

We've induced the labor, but maybe things need more help along the way.

Let's talk about amnioinfusion.

This is where you inject sterile saline or lactated ringers into the uterus through a special catheter.

And why would you do that?

It's usually done if there's oligohydramnios, which means low ambiotic fluid.

It replaces the cushion for the umbilical cord to relieve variable decelerations caused by cord compression, and it effectively floats the cord.

Then there's the move to flip a breech baby, external cephalic version or ECV.

Right, this is done around 36 to 38 weeks.

Using ultrasound guidance, the doctor literally pushes on the abdomen to manually turn the fetus from a breech position to head down.

It sounds intense.

It can be quite uncomfortable for the mother, for sure.

And there are risks.

You don't do it if there's a previous C -section, low ambiotic fluid, or a multi -fetal gestation.

What's the nurse's role?

The nurse needs to monitor for vaginal leaking afterwards, do the membranes rupture during all that pushing,

and for contractions.

Also, and this is important, if the mom is Rh negative, she needs rogum.

Why?

Because there might be some minor blood mixing between mom and baby during the manipulation.

Okay, now let's get to the delivery room floor.

The mom is pushing, but she needs some help.

We're talking instrument -assisted birth, forceps, and vacuum.

Right.

These are used to provide traction or sometimes rotation to get the baby out.

Forceps are those curved blades that fit around the fetal head.

A vacuum is a suction cup that attaches to the scalp.

And why would we need to use them?

What are the indications?

Well, a big one is maternal exhaustion.

She just physically can't push anymore.

Or maybe she has an inability to push effectively,

perhaps due to a cardiac issue, where the Valsalva maneuver is dangerous for her.

Or fetal distress.

Or fetal distress, exactly.

The baby needs to come out now.

But they can leave a mark, and this is where the nurse plays a huge role in patient education, right?

A huge role.

Parents see these marks and they worry.

Forceps can sometimes cause a temporary facial nerve injury in the baby.

You might see facial asymmetry when they cry.

The vacuum creates a circular scalp swelling called a chignon.

It looks like a conehead.

You need to reassure parents that these things usually resolve on their own in a few days.

What are the risks for the mom?

For the mom, the big risks are lacerations or hematoma.

And how do we spot a hematoma?

What's the key sign?

Severe, unrelenting pain.

If she has an epidural and still complains of intense pressure or pain in her perineum or rectum, you have to suspect a hematoma.

It's a collection of blood in the tissue and it is excruciating.

And if those don't work or aren't an option, we have the cesarean birth.

The text notes the rate in Canada is about 28%.

That's a significant number, almost one in three births.

And there are strategies to reduce this, like continuous labor support, using peanut balls, and encouraging trials of labor after a previous C -section.

But sometimes it is medically necessary.

What are the main indications?

Things like cephalopelvic disproportion,

or CPD where the baby's head is physically too big for the mother's pelvis,

or active herpes, placenta previa, placental abruption, or a cord prolapse.

I want to clarify the incisions because this confuses students and it is so critical for future pregnancies.

There's the skin incision and then there's the uterine incision.

They aren't always the same.

This is a crucial distinction.

The skin incision is usually a transverse cut, the bikini cut, or fan steel.

It heals well aesthetically.

But the uterine incision is what dictates the safety of future births.

Okay, so let's break down the types of uterine incisions.

The low transverse is the preferred one.

It cuts into the lower uterine segment, which is thinner and less active during contractions.

It's the least likely to rupture in a future pregnancy and it's what makes a VBAC vaginal birth after cesarean possible.

And the other main type.

The classic incision.

This is a vertical cut high up in the uterine corpus, right into the thick contracting muscle.

And the classic is the deal breaker for future vaginal births.

Yes, it has a much higher risk of rupture because that muscle takes the brunt of the force during contractions.

If a woman has a classic incision, she must have C -sections for all future pregnancies.

It's not an option.

Okay, walk us through the nursing care.

It's surgery, but it's also a birth.

It's a very unique situation.

It is.

Pre -op involves getting labs like a CBC and clotting studies.

The patient is NPO and we give an antacid medication to reduce gastric acidity in case of aspiration during anesthesia.

And a Foley catheter.

A Foley catheter is placed to drain the bladder and keep it out of the way so it doesn't get nicked during the surgery.

And intraoperatively.

We do a time -out safety checklist, just like in any other surgery.

The partner is usually there, seated at the head of the bed.

Figure 8 .4 shows this well.

And the nurse supports the partner, too.

They often terrified.

Post -op, you are checking the fundus, the top of the uterus.

But you have to be careful.

It's a fresh surgical site.

The tech says to gently walk the fingers from the side to the midline.

Don't just match down on it like you might for a vaginal birth.

It hurts.

And what else are you assessing?

You also assess lochia, the vaginal bleeding and the incision dressing for any signs of bleeding or infection.

Pain management is vital.

It is.

We use PCA pumps or patient -controlled analgesia and sometimes epidural narcotics.

And early ambulation and deep breathing are key to prevent DVT blood clots and pneumonia.

The text also touches on the emotional side of an unplanned c -section.

Yes.

And this is so important.

Nursing care plan 8 .1 highlights addressing feelings of guilt or failure.

The nurse needs to validate that it's okay to mourn the birth experience you wanted, even if you have a healthy baby.

The emotional support is a huge part of our job.

Okay.

Let's move on to abnormal labor or what the text calls dysfunctional labor.

It uses the 5PS framework.

This is a classic nursing mnemonic.

It is.

If labor isn't progressing, it's usually a problem with one of these.

Powers, passenger, passageway, position or psyche.

Let's start with powers, the contractions.

They can be too much or too little.

Right.

So you can have hypertonic labor.

This usually happens in the latent phase, so early labor, less than four centimeters dilated.

What does that look like?

The contractions are frequent.

They're cramp -like and they're painful, but they are ineffective.

They aren't dilating anything.

The uterus has a high resting tone, so it's not relaxing between them.

So the mom is in pain.

She's getting tired and she's frustrated because she isn't making any progress.

Exactly.

The management is therapeutic rest,

maltidation, a warm shower or bath.

The goal is to let the uterus relax so it can reset and start a normal, effective pattern.

Now contrast that with hypotonic labor.

Hypotonic labor happens later in the active phase, so after four centimeters, the contractions were good, but now they've weakened or stopped altogether.

The uterus is too relaxed.

What causes that?

This is often caused by overdistension of the uterus from twins, or too much fluid, which is called polyhydramnios.

The muscle is just stretched too thin to contract well.

And the fix here is what we talked about earlier, maybe an amniotomy to break the water or starting oxytocin to stimulate the muscle.

Precisely.

Next P,

the passenger, the fetus, size matters.

Macrosomia is an infant over 4 ,000 grams.

And that brings the risk of shoulder dystocia.

This is a true nightmare scenario in the delivery room.

The head is born, but the shoulders get stuck behind the pubic bone.

It's a major emergency.

What does the nurse do?

You have to know what not to do first.

Do not push on the fundus.

Why not?

Pushing on the top of the uterus just jams the shoulder harder against the bone.

It can make things worse and even cause injury.

So what do you do instead?

You apply suprapubic pressure pushing with your fist right above the pubic bone to try and dislodge that anterior shoulder.

And you perform the McRoberts maneuver.

Describe that for us.

This involves flexing the mother's thighs sharply back against her abdomen.

It tilts the pelvis and opens the ankle, which can free the shoulder.

And after the baby is out, you have to do a specific assessment.

Check the infant for a clavicle fracture.

You look for crepitus, which is a crunching over the collarbone, or a unilateral moro reflex.

One arm startles, the other doesn't move as much.

The passenger can also be in the wrong position.

Oh, absolutely.

Oxiput posterior, the sunny side up baby.

The back of the baby's head is against the mother's spine.

This causes what we call back labor.

Intense, constant back pain.

It makes labor longer and more painful.

Boy, there's a breech presentation.

Right.

And there are different types, as shown in figure 8 .6.

Frank breech, where the legs are up by the head.

Full breech, where the baby is sitting cross -legged.

Or footling breech, where one or both feet are first.

What's the biggest risk with a breech birth?

The biggest risk is head entrapment.

The body is smaller and it slips out.

But the cervix can clamp down on the neck before the larger head is born.

That's a huge emergency.

And it's why a C -section is so common for breech presentations.

Okay, what about the passageway and the psyche?

Pathway is the pelvis.

A gynecoid pelvis is the best shape for birth.

But a very common soft tissue obstruction is simply a full bladder.

A full bladder?

Yes.

It takes up space in the pelvis that the baby needs to descend.

So a key nursing intervention is to make sure the bladder is empty.

Sometimes just doing that is enough to get labor to progress again.

And psyche, this isn't just about attitude, it's biology.

It is.

Stress and anxiety release epinephrine and cortisol.

These are fight or flight hormones.

They actually inhibit uterine contractility.

And they consume glucose that the uterus needs for energy.

So a stressed, fearful mother physically cannot labor as well.

That's right.

This highlights the importance of one -to -one nursing support.

Keeping her calm, making her feel safe.

That is a medical intervention.

The text mentions the Friedman curve when talking about the duration of labor.

Yes.

It's a graph that's used to track labor progress over time.

If the progress is too slow, it's prolonged labor.

And that brings the risk of infection, maternal exhaustion, and hemorrhage.

And what if it's too fast?

If it's too fast, a precipitate birth, which is completed in less than three hours, there are different risks.

Things like uterine rupture, severe lacerations, and even fetal intracranial hemorrhage from the rapid pressure changes on the baby's head.

So for a precipitate birth, the management is just trying to support the woman through the panic and then dealing with the aftermath.

Pretty much.

And applying cold packs to the perineum for the breathing because it's usually significant.

Let's look at other considerations in labor.

These aren't necessarily emergencies, but they are complicating factors.

Let's start with obesity.

The text defines this as a BMI over 30.

And it notes several increased risks.

DVT, infection, hemorrhage, and also difficulty monitoring the contractions and the fetal heart rate accurately.

And there are practical nursing needs.

Absolutely.

You need larger equipment.

Getting an appropriate blood pressure cuff is vital.

Larger gowns, sturdy tables.

It's about providing care with dignity and safety.

You also need to pay special attention to the incision in a C -section because the skin folds can harbor moisture and bacteria, increasing infection risk.

Then there's the acronym SUP, PROM and PPROM.

Right.

PROM, premature rupture of membranes.

This is a rupture more than one hour before labor starts a term.

So after 37 weeks.

And PPROM.

PPROM,

premature rupture of membranes.

This is a rupture before 37 weeks.

How do we diagnose it?

Sometimes it's a huge gush, but sometimes it's just a slow leak.

We use nitrazine paper.

It turns blue if it touches amniotic fluid because the fluid is alkaline.

Or we look for a ferning pattern of the dried fluid under a microscope.

And the big risk here is infection, specifically corioamnionitis.

So the nursing rule is minimize invasive procedures.

No digital vaginal exams if she's not in active labor because every exam introduces bacteria.

And what else do you monitor?

You monitor her temperature for any signs of fever over 38 degrees Celsius.

You report any foul odors from the vaginal discharge and you watch for fetal tachycardia, which can be an early sign of infection.

Okay, what about preterm labor itself?

Labor that occurs between 20 and 37 weeks.

The diagnosis involves checking the cervical length via ultrasound.

A short cervix is a strong predictor.

And looking for fetal fibronectin, or FFN.

If the FFN test is positive, she's likely to deliver in the next week or so.

And the management involves two main categories of drugs, tocolytics and steroids.

Cocolytics are drugs to stop or slow contractions.

Magnesium sulfate is a big one.

It relaxes the smooth muscle of the uterus.

But it has another important function too, right?

Yes, a crucial one.

We also use it because it offers neuroprotection for the fetus.

It helps protect the premature brain against cerebral palsy.

Endomethacin is another tocolytic mentioned.

And for the baby's lungs?

Steroids.

Specifically, betamethasone.

It's usually given as two doses 24 hours apart.

It speeds up the production of surfactant in the fetal lungs so they can breathe if they're born early.

Okay, on the complete other end of the spectrum, prolonged pregnancy.

Going past 42 weeks.

The placenta really has an expiration date.

As it ages, it can become insufficient.

It gets calcified.

And what are the risks to the baby?

The fetus can actually start to lose weight.

The skin can get dry and peel, which is a sign of post -maturity syndrome.

And there is a high risk of meconium aspiration because the stress of the aging placenta can cause the baby to pass stool in utero.

So we monitor them closely.

Very closely.

Kick counts, non -stress tests.

And induction is usually recommended by 41 weeks and 6 days to avoid these risks.

Alright, we are at the final, most intense section of the chapter.

Emergencies during childbirth.

These are the life and death situations where seconds count.

Let's start with prolapsed umbilical cord.

This often happens right after the membrane's rupture.

The cord slips down below the presenting part of the fetus.

The head comes down and pinches the cord against the pelvis, completely cutting off the baby's blood and oxygen supply.

There are different types mentioned in the text.

Yes.

A complete prolapse is where the cord is visible at the vaginal opening.

A calpated prolapse is where you can feel it during a vaginal exam.

And an occult prolapse is hidden, but you suspect it because of what the fetal heart rate is doing.

Okay, visualize this.

You are the nurse.

You are doing a vaginal exam or you're just checking the monitor and you see the heart rate crash into a deep prolonged deceleration.

You do an exam and you feel a pulsating loop of cord.

What do you do?

This is critical.

Do not remove your hand.

You push the fetal head UP and off the cord to restore blood flow.

You are physically holding the baby off its own lifeline.

And you stay like that.

You keep your hand there while the team rushes the bed to the operating room for an emergency C -section.

You are the baby's lifeline until it is born.

And you need to use gravity.

Yes.

You get the mom into a knee chest position, face down, butt in the air, or drendel and burg.

The whole bed is tilted so her hips are elevated.

You want gravity to pull the baby back out of the pelvis.

Next emergency.

Uterine rupture.

This is the complete separation of the uterine muscle.

The wall of the uterus literally tears open.

It's a high risk for those with previous classic C -sections or from tachycycli caused by too much oxytocin.

What are the signs?

It's not always obvious bleeding, is it?

No.

It can be a sudden loss of the feel heart rate signal because the baby is now floating out into the abdomen, a sudden cessation of contractions.

The abdomen might feel rigid.

And there's a very specific symptom, the text notes?

Yes.

Chest pain or pain between the scapulae, the shoulder blades.

Shoulder pain, why?

It's referred pain.

The internal bleeding irritates the diaphragm and that nerve pain is felt in the shoulder.

That is a massive red flag.

This requires immediate surgery and often a hysterectomy to save the mother's life.

Let's talk about placenta accreta.

This is an abnormal attachment of the placenta into the uterine wall.

It grows too deep into the muscle.

And the problem occurs after the baby is born.

Exactly.

It won't detach after birth during the third stage of labor.

Trying to remove it causes profuse life -threatening hemorrhage.

It may require a hysterectomy to control the bleeding.

And finally, the last one, amniotic fluid embolism or anaphylactoid syndrome.

This is very rare, but it's often fatal.

Amniotic fluid somehow enters the maternal circulation maybe through a small tear in the corian.

It travels to our lungs and triggers a massive immune response.

It looks like anaphylactic shock.

It looks exactly like that.

The signs are a sudden, profound hypotension, hypoxia, and then cardiac arrest.

This is often followed by a complete coagulation failure, or DIC.

And the response is just everything.

It's a full code.

CPR, intubation, massive transfusion of blood products, and immediate mobilization of the entire team.

Phew.

That is a lot of heavy information.

We went from how to get labor started to how to save a life in, well, less than an hour.

It is heavy.

But if we pull back and look at the summary of this deep dive, what really stands out is the nurse's role in all of this.

It's woven through every single topic.

It's not just about following orders.

It's about critical thinking.

It's not.

It's assessment.

It's catching that tachycystole early on the monitor.

It's safety.

It's double checking the bishop's score before you even think about starting oxytocin.

And it's support.

And it's support.

It's holding the hand of a woman who is in that knee chest position, terrified.

Or it's explaining what that vacuum cup mark is to a frightened partner.

It's balancing all of those medical interventions with the humanity of birth.

That is the core of Chapter 8.

It's the art and the science of nursing.

We really hope this walkthrough helps you feel a little more prepared for that exam or that shift on the labor and delivery ward.

Study those bishop scores, know your incision types, and please remember,

stop, turn, oxygen.

A warm thank you from the Last Minute Lecture Team.

Good luck out there.