Special Considerations for Individualized Care of the Laboring Woman



Special Considerations for Individualized Care of the Laboring Woman


Suzanne McMurtry Baird

Betsy Babb Kennedy

Jennifer Dalton








Part 1 Age-Related Pregnancy Considerations


Teen Pregnancy


Teen pregnancy is a multifactorial issue that is not, unfortunately, a new phenomenon. The birth rate for 15- to 19-year-olds is 26.5 per 100,000 teenagers aged 15 to 19 years—down 10% from 2012 for all races and the lowest ever reported in the United States.1 However, the United States teen pregnancy rate remains significantly higher than other Western industrialized nations. In addition, social and racial disparities exist with higher pregnancy rates in non-Hispanic black, Hispanic/Latino, American Indian/Alaskan Native, and the socioeconomically disadvantaged of any race.1 Many factors contribute to the rate of teen pregnancy, who are psychologically and physiologically vulnerable. Some of these influential factors include2:



  • Education


  • Low socioeconomic status


  • Low income


  • Underemployment


  • Neighborhood—physical disorder, income level

The teen who becomes pregnant must accomplish both the developmental tasks of adolescence as well as pregnancy. Assuming adult roles (having a baby) before completing the work of adolescence can have significant long-term consequences that include:



  • Prolonged dependence on parents/family/society


  • Education: only 50% graduate high school by age 22 and less than 2% graduate college by the age of 303


  • Higher rates of depression and low self-esteem


  • Higher rates of child abuse and neglect


  • More likely to be incarcerated4


  • More likely to become teen parents themselves (repeating the cycle)


Teen pregnancy is a risk of poor perinatal outcomes, which may be related to nutrition, lack of prenatal care, or the ability to access health care and social services.5 These risks include:



  • Iron deficiency anemia: exacerbated in pregnancy; prenatal vitamins and increased intake of iron-rich foods should be encouraged.


  • Preterm labor and birth: during prenatal care discuss the subtle signs and symptoms of preterm labor and when to contact provider.


  • Low–birth-weight infants: closely tied to preterm birth and maternal weight gain.


  • Preeclampsia: one of the most common complications of teen pregnancy.


  • Higher rates of cephalopelvic disproportion: more common in younger teens who have not completed their physical growth.6

Physical care for the teen during labor does not differ from other labor patients. However, the teen may require additional support and encouragement from family and the healthcare team. Social work should be consulted when the teen is admitted in order to begin the process for activation of community supportive services and fulfill any state reporting requirements.
Referrals to well-baby clinics, programs for school-aged mothers, community organizations, and state social service organizations may provide needed support.


Extensive teaching occurs during the postpartum period (for an in-depth discussion on postpartum education, refer to Module 17). Education should be “teen friendly” and include the mother’s family/support members since they will be involved in care and future health decisions. After birth, careful assessment of the teen mother should be done to determine her knowledge regarding infant and self-care. As the nurse, you may need to spend additional time observing the mother’s interactions with her infant. Teens may have unrealistic views of the reactions of their infants, and get frustrated easily. Early return to their obstetric provider may be of benefit for assessment of complications and to reinforce teaching concepts. Teen-specific education areas are listed below.


Breastfeeding

Teen mothers are less likely to initiate and sustain breastfeeding. Focused education during the prenatal and postpartum periods should include not only nutritional and immunologic benefits of breastfeeding, but also financial, decreased interpregnancy rates, and improved mother–infant bonding.5


Depression

Even though postpartum depression screening is routine, obstetric providers should be aware that teen mothers experience higher rates of depression. There are several published screening tools that may be utilized.


Birth Control

The Centers for Disease Control (CDC) has set prevention of teen pregnancy as one of their public health priorities.7 It is estimated that 35% of recently pregnant adolescents experience a rapid repeat pregnancy increasing the risk of preterm birth, low birth weight, and small for gestational age.8 Repeat pregnancy within 2 years may also impact the mother’s ability to finish education and pursue job opportunities.8 Since the vast majority of teen pregnancies are unintended, there should be an education focus on methods of birth control and prevention of sexually transmitted infections. Long-acting reversible contraceptive methods, such as intrauterine devices and contraceptive implants, are effective and are recommended for adolescent women.9


Advanced Maternal Age (35 Years or Older)


Even though the overall number of births each year has declined, the number of women over age 35 years who give birth and the mean age at which women give birth have risen steadily since 2000.7 There are several factors that have contributed to this trend, such as:



  • Availability of effective birth control options


  • Increased number of women pursuing advanced education and delaying parenthood until they are professionally established


  • The increase in later marriage and second marriages


  • The increased availability of assisted reproductive techniques


Adverse pregnancy outcomes are associated with advanced maternal age. With the exception of pre-existing health issues such as hypertension, obesity, or diabetes, the pathogenesis of adverse outcomes is not well understood. In addition, it is unclear at what age after 35 that risk increases. In general, it is thought that after age 35, risks continue to increase with age.



  • Fetal chromosomal abnormalities


  • Fetal congenital malformations



  • Ectopic pregnancy


  • Spontaneous abortion


  • Stillbirth


  • Placenta previa


  • Maternal mortality


  • Pre-existing medical conditions, such as chronic hypertension or diabetes


  • Cesarean birth (elective and emergent)


  • Preeclampsia


  • Gestational diabetes


  • Preterm birth


Care of the woman over 40 years in labor does not differ physically from care of other laboring women. If the woman has other medical conditions, such as diabetes or hypertension, care needs are modified to include interventions related to these conditions.

In the postpartum period, the provider should be aware that the older woman may find the childbirth experience and care of a newborn more exhausting than anticipated. The postpartum period may be a time of social isolation as well. The woman who gives birth after age 40 years may find that her peers are more likely to be the parents of adolescents and young adults and removed from the concerns of a new mother. Another concern for the older woman who gives birth is that she may be part of the “sandwich generation.” These are women who are caring for elderly parents as well as children, which may be emotionally, physically, and financially draining.



Part 2 Women with a Physical Disability

The woman with a physical disability who presents for care during pregnancy may need specific modifications related to her condition. Care should be designed so that needs are planned and potential problems are addressed. Prejudices may exist regarding the ability of the disabled to give birth and parent successfully, and the care provided should be positive and supportive. Care for the woman with a disability needs to be comprehensive and interdisciplinary. When the needs related to the pregnancy and the woman’s disability is fully met, her ability to have a positive birth experience is facilitated.


At the first prenatal visit, it is important to explore support, assistance, or modifications the woman feels are necessary. A complete and open discussion is essential so that any requests can be initiated. In anticipatory planning, it is also important to discuss any assistance she feels she will need to care for her infant after birth. The provider should be careful not to convey the message that because she is disabled she is not competent. However, if assistance will be required, it is best to know ahead of time and make plans. Some women require assistance, some may require modifications to their homes, some require adaptive equipment, and some do not require anything different from every other new mother.

Known disease specific complications or limitations, such as decreased balance, spasticity and muscle weakness, altered gait, reduced bone density, osteoporosis, comorbidities, certain medications, and dietary imbalances place the woman with a disability at higher risk for falls.1 Pregnancy further enhances risk for falls as the woman’s body habitus changes from the enlarging uterus, and the center of gravity shifts. Assistive devices, such as a wheelchair, braces, or a walker may be needed to decrease fall risk. Avoiding excessive gestational weight gain, continuing with range of motion and stretching exercises may improve mobility during pregnancy.2 When the woman is admitted to the hospital setting, an environmental assessment is recommended in order to improve safety. Remove any unnecessary equipment in the room and map out best paths within the hospital room for mobilization. The bed should be kept in the lowest position with wheels locked and call lights placed within the woman’s reach at all times. Signage placed outside and/or within the woman’s room to indicate that she is at high risk for a fall is indicated according to defined hospital practices.2

NOTE: Dietary deficiencies are common in women with physical disabilities—access to healthy foods, difficulty in chewing, dysphagia, or gastric absorption delays. Pregnancy may compound these deficiencies and result in physiologic anemia or fetal growth issues.1


Decisions regarding mode of delivery should be made based on obstetric indications. The woman, her provider, and her disability specialist should collaborate to discuss any issues that might impact the mode of delivery. Vaginal delivery is possible for many disabled women and is the preferred mode of delivery whenever possible. Cesarean birth should never be done arbitrarily because of a disability. Anesthesia may be a concern, especially in women with spinal cord injuries or other neurologic conditions. A consultation with an anesthesiology provider before labor is suggested so that a comprehensive plan for pain management can be developed.


During labor and/or regional anesthesia, monitor the woman’s bladder status and prevent overdistention. Consider “laboring down” for second stage management to prevent fatigue and anticipate the potential need for operative vaginal birth. Depending on physical limitations, positioning for birth may require modifications.2

Needs during the postpartum period vary based on changes that may have occurred during pregnancy and birth. A more prolonged recovery and hospitalization may be necessary and should be assessed on a case-by-case basis. Breastfeeding should be encouraged, although some modifications and adaptive equipment may be required, especially if the disability involves the upper extremities. Lactation consultants are helpful in identifying positions and adaptive equipment needs that will facilitate successful breastfeeding. Consider consultation with an occupational therapist for a home visit as indicated to identify equipment that can be used in the home environment for infant and self-care. Such equipment may include cribs that are low or that attach to wheelchairs. Also consider the need for home health follow-up and make the referral, if needed. Include the woman and her family in all discussions. Table 14.1 outlines an example care plan.








TABLE 14.1 PLAN OF CARE FOR WOMEN WITH A PHYSICAL DISABILITY IN PREGNANCY


















Goals:


  • Management of symptoms
  • Prevention of complications
  • Optimization of function
  • Understanding of self-care and demonstrates necessary psychomotor skills for care after discharge
Preconception

  • Family planning
  • Counsel regarding risks
  • Determine medication dosing based on disease symptoms and remission
  • Physical and cognitive assessment
Antepartum

  • Monitor for progression of symptoms or effects of disease on physical and mental abilities
  • Determine modifications in medications (as indicated)
  • Collaborate with physical therapy to develop plan for care needs
  • Fall risk teaching with physical changes of pregnancy
  • Assess for asymptomatic bacteruria
  • Plan labor and birth care needs (may require preadmission care conference)
  • Preadmission assessment with anesthesiology
Labor and Birth

  • “Labor down”/passive descent during second stage of labor to decrease energy utilization and likelihood of fatigue
  • Assist with positioning to facilitate vaginal birth
  • Prepare for possible operative vaginal birth (as indicated based on physical needs)
  • Pain management as indicated and desired
  • Cesarean birth for obstetrical needs
Postpartum

  • Fall risk in women with physical symptoms and fatigue

    • Assist with ambulation until demonstrated ability
    • Utilize adaptive aids as necessary
    • Fall precautions implemented

  • Evaluate safe environment
  • Infection control precautions
  • VTE prophylaxis as indicated
  • Anticipate need for assistance with care of woman and newborn
  • Space care activities over time to decrease fatigue
  • Breastfeeding is encouraged

    • Evaluate safety of medications

  • Monitor for progression of symptoms
  • Prevent overdistention of bladder

    • Utilize bladder scanner as indicated

  • Physical therapy consult as indicated
  • Occupational therapy consult as indicated
  • Nutritional consult as indicated
  • Dietary modifications with swallowing difficulties
From Baird, S. M., Dalton, J. (2013). Multiple sclerosis in pregnancy. Journal of Perinatal and Neonatal Nursing, 27(3), 232–241.



Part 3 Obesity

Since 1980, the prevalence of obesity has more than doubled worldwide. The World Health Organization considers obesity one of the most serious global health problems of the 21st century.1 Obesity is defined as a body mass index (BMI) of greater than or equal to 30. In 2014, 34.9% of the adult population in the United States was obese.1 Table 14.2 outlines the WHO classification of weight based on BMI.








TABLE 14.2 WORLD HEALTH ORGANIZATION CLASSIFICATION OF WEIGHT


















WORLD HEALTH ORGANIZATION CLASSIFICATION OF WEIGHT
Normal weight BMI 18.5–24.9
Overweight BMI 25–29.9
Obese BMI 30–39.9
Morbidly obese BMI 40 or more
From World Health Organization. (2015). Obesity and overweight. WHO. www.who.int.easyaccess2.lib.cuhk.edu.hk/mediacentre/factsheets/fs311/en/ . Accessed January 23, 2015.

NOTE: To calculate BMI:


Recent data describe obesity as it occurs in women:



  • Prevalence of women with BMI >25 has more than doubled in the last 20 years.2


  • A total of 56% of women of child-bearing age are overweight, 30% are obese, and 8% morbidly obese.3,4


  • Pregnancy is associated with permanent weight increase in every BMI category.5


Prenatal Care

Each visit to an obstetric provider should include a head-to-toe assessment, with special attention to weight gain/loss trends. For morbidly obese women, a bariatric scale may be required for weight assessment. In 2009, the Institute of Medicine6 published guidelines for recommended gestational weight gain based on prepregnancy BMI (Table 14.3). Since 2009, when the recommendations were published, additional research has been conducted which indicates that no weight gain or even weight loss in obese or morbidly obese patients decreases rates of
preeclampsia, macrosomia, cesarean and operative vaginal births, neonatal admissions to the NICU, and improves APGAR scores.7








TABLE 14.3 IOM GUIDELINES



















Institute of Medicine guidelines for recommended gestational weight gain based on prepregnancy body mass index (2009)
PREPREGNANCY BODY MASS INDEX TOTAL WEIGHT GAIN RANGE (lb)
Underweight (less than 18.5 kg/m2) 28–40
Normal weight (18.5–24.9 kg/m2) 25–35
Overweight (25–29.9 kg/m2) 15–25
Obese (greater than 30 kg/m2) 11–20


Obese women are at increased risk of complications and often enter pregnancy with pre-existing comorbidities such as chronic hypertension, type 2 diabetes, obstructive sleep apnea, and/or hypercholesterolemia.4,8

NOTE: The higher the mother’s BMI, the higher her risk of developing complications during or after pregnancy.4








TABLE 14.4 MATERNAL RISKS
































Gestational diabetes

  • 3–8 times higher risk of developing gestational diabetes vs. normal weight women due to insulin resistance9
Hypertension

  • 50% will develop preeclampsia5
  • For accurate assessment of blood pressure, make sure the appropriate sized cuff is used—cuff that is too small gives a falsely elevated reading
Prolonged or dysfunctional labor

  • Prolonged labor as BMI increases
  • Decreased uterine contraction intensity10
  • High cholesterol levels may prolong or cause dysfunctional labor11
  • Rate of failed induction is two times that of normal weight women11
Operative vaginal and cesarean birth

  • Due to macrosomia and dysfunctional labor patterns11
Anesthesia

  • Difficult due to positioning, obscure landmarks, adipose tissue12
  • May impair pain management during labor12
  • Difficult airway risk12
  • Higher risk of aspiration if general anesthesia used12
Postoperative

  • Wound breakdown4
  • Dehiscence4
Infections

  • Increased risk of surgical site infections4
  • Endometriosis rates increased4
Venous thromboembolism (VTE)

  • Obesity and pregnancy both increase risk of VTE8
  • Early use of sequential compression devices and early ambulation decrease the risk of venous thrombus formation
Sleep disordered breathing

  • Physiologic changes of pregnancy that increase risk
  • Nasopharyngeal edema
  • Decreased functional residual capacity
  • Increased waking at night
  • Weight gain13
Maternal death

  • Associated with aspiration, failed intubation, hemorrhage, thromboembolism, and stroke
  • Cesarean section also increases mortality due to prolonged operative time, wound infection, dehiscence, endometritis, atelectasis, and pneumonia14


When obese women are admitted for delivery, it may be necessary to use special bariatric equipment including beds, wheelchairs, bedside commodes, and operating room table extensions. Lifts and other devices for repositioning and transport of obese women should be available for safe patient handling and prevention of work related injury to care providers. Table 14.6 is an example care plan for the obese woman.









TABLE 14.5 FETAL/NEWBORN RISKS


























Spontaneous miscarriage

  • 2–3-fold increase in early miscarriage15
Congenital anomalies

  • Twice as likely to have a fetus with a neural tube defect compared to a woman of normal weight15
  • Higher rates if combined with diabetes
Stillbirth

  • Rate double that of normal weight women16
Prematurity

  • Data shows higher incidence
  • Indicated birth due to other risk factors17
Macrosomia

  • Twice as common in obese women due to gestational diabetes
  • Greater risk of hypoglycemia7
Birth injury Due to macrosomia7
Breastfeeding

  • Obese women are less likely to breastfeed due to:

    • Mechanical issues of positioning
    • Maternal issues from birth such as prolonged labor, cesarean delivery, or postpartum complications
Childhood obesity

  • Babies born to obese mothers are more likely to develop obesity by the time they reach the age of 418


Admission

Obese women are less likely to have spontaneous labor.4 When the woman is admitted for birth (spontaneous or induced), complete a full risk assessment that includes medical disease and surgical history, complications associated with previous and current pregnancy. Assessment regarding symptoms or a previous diagnosis of obstructive sleep apnea is also recommended on all obese women due to a predisposition of right-sided heart failure and secondary pulmonary hypertension.19 The use of a pulse oximeter may be helpful to alert the provider to any signs of maternal hypoxemia, especially in women with sleep apnea or those who have received medications associated with respiratory depression.5 The following screening questions in Table 14.7 are helpful in screening.

Determining fetal position may be difficult depending on the body habitus of the woman. By palpating the abdomen, try to determine the outline of the uterus and establish fundus first. Ask where she feels fetal movement and use information to establish fetal contours. If unable to determine fetal position, an ultrasound examination may be necessary—which may also be difficult.

Morbidly obese mothers are two times more likely to deliver a baby weighing greater than 4,500 g, and more likely to be admitted to the neonatal intensive care unit due to low APGAR scores.7 These risks in combination with medical complications (diabetes) consider having the neonatal team at birth.


Labor

The class II and III obese woman is a high-risk patient. Nurse-to-patient ratio during active labor is recommended 1:1 per AWHONN staffing guidelines.22 There may be need for 2:1 staffing during procedures such as positioning for epidural, holding legs in vaginal birth, position changes or holding the pannus away from the field in vaginal birth or cesarean section.

In the absence of other comorbidities or complications, obesity alone is not an indication for elective birth prior to 39 weeks.8 However, more frequent induction of labor is related to comorbidities and higher incidence of post-dates pregnancy. If labor is induced, there is a higher incidence of failed induction with slower and less productive labor progression due to adipose tissue production of leptin, which can inhibit contractions. In combination with difficulty in monitoring uterine contractions, higher doses of oxytocin may be utilized. If the woman is attempting a vaginal birth after cesarean (VBAC), trial of labor failure rates reach as high as 39%.4

Positioning for comfort and optimizing physiologic status may be difficult due to diminished lung capacity, chest wall compliance, gas exchange, functional residual capacity, and an

increased work of breathing in obese patients.19 An upright or semi-Fowler’s position facilitates lung expansion, maternal comfort, and labor progress. As with all pregnant women, it is especially important to avoid a supine position to prevent pressure on the uterus and venacaval syndrome.19








TABLE 14.6 PLANNING FOR CARE OF THE OBESE WOMAN DURING LABOR
















Goals:

  • Effective fetal and uterine monitoring with ability to monitor progress of labor and fetal status
  • Adequate pain control during labor, birth, and postpartum
  • Expected labor progress
  • Vaginal birth
Prior to Admission

  • Determine facility capabilities

    • What is the toilet weight limit?
    • Can the woman get into the shower?

  • Determine equipment needs for labor and birth
  • Preanesthesiology evaluation

    • Informed consent
    • Airway (e.g., fiberoptic intubation capability)
    • Equipment/supply needs (e.g., epidural needles)
    • Comorbidities
    • Cardiac and respiratory evaluation

  • Emergency preparedness—conduct drills to determine needs

    • Does the bed move through the doorway if emergent transport to the OR is indicated?
    • How many staff members will it take to transport patient in an emergency?

  • Informed consent by provider
Bariatric equipment needs (on site or rental)

  • Scales
  • Examination table
  • Bed
  • OR table or extenders
  • Stirrups
  • Wheelchair
  • Commode
  • BP cuff (up to 60 cm arm circumference)
  • Lifting/transfer equipment (e.g., air assisted lateral transfer, power transport gurney, sit to stand, lifts)
  • Hospital gowns
Instruments

  • Speculum—extra long
  • Retractors—extra long
  • Difficult intubation
Admission

  • Complete a risk assessment
  • Notify anesthesiology team and develop plan of care for pain management and emergency needs
  • Determine staffing needs

    • 1:1 RN to patient ratio recommended if continuous EFM required
    • Extra staff for positioning, transfer, and/or transport assigned
    • OR staff for retraction during vaginal birth assigned

  • Obtain needed equipment and supplies
  • If cesarean section is required:

    • Aspiration prophylaxis
    • Antibiotic dose increase
    • Thromboprophylaxis: Sequential compression devices placed prior to surgery; risk assessment for heparin therapy depending on anesthesia type and duration
    • Extra scrub personnel for retraction
    • Appropriately sized instruments
Postpartum

  • Evaluate fall risk and implement necessary precautions
  • Early ambulation according to patient’s condition and provider orders; sequential compression devices remain on until ambulation
  • Evaluate vaginal bleeding frequently since uterine position/tone assessment and massage may be difficult
  • Assist with breastfeeding positioning
  • Lactation consultation as needed
  • Observe for signs and symptoms of infection
  • Educate woman/support regarding signs and symptoms of pulmonary embolus
  • Dietary consult as indicated
  • Occupational therapy consult as indicated
  • Assess discharge needs
  • If patient has suspicion or confirmed diagnosis of sleep apnea, monitor with pulse oximetry post-op and consider continuous positive airway pressure (CPAP) as indicated
  • Respiratory therapy consult as indicated
From Gunatilake, R. P., Perlow, J. H. (2011). Obesity and pregnancy: Clinical management of the obese gravida. American Journal of Obstetrics & Gynecology, 204(2), 106–119; James, D. C., Maher, M. A. (2009). Caring for the extremely obese woman during pregnancy and birth. Maternal Child Nursing, 34(1), 24–30; Kribs, J. M. (2014). Obesity in pregnancy: Addressing risks to improve outcomes. Journal of Perinatal and Neonatal Nursing, 28(1), 32–40.








TABLE 14.7 SCREENING QUESTIONS




Screening Questions for Obstructive Sleep Apnea

  • Do you snore?
  • Do you wake up tired after a full night’s sleep?
  • Do you fall asleep during the day?
  • Have you been told you stop breathing at night while you are sleeping?
  • Do you have a history of hypertension?
Note: If “yes” to 2 or more questions, refer to a Sleep Specialist

External fetal monitoring is challenging in obese women due to maternal body habitus and may require a nurse to remain at the bedside in order to hold the monitor in place for continuous monitoring. Evaluation of uterine activity by palpation may also be difficult or impossible due to abdominal adipose tissue. Internal monitoring, when possible, may give the most accurate information regarding fetal heart rate and uterine activity. There are available adjunct fetal monitoring devices available to assist with continuous and more accurate fetal and uterine monitoring.

Because obese women are at increased risk for labor dystocia and prolonged labor, accurate assessment is very important.10 The benefit of internal monitoring during active labor once membranes are rupture may be considered. However, artificial rupture of membranes in early labor for the purpose of internal monitoring is not recommended.

Progress of labor should be carefully monitored, as obese women may have prolonged labor, a dysfunctional labor pattern, and failure of descent (refer to Module 6 for a review of labor management issues).10 All of these factors increase the risk of a cesarean and operative vaginal birth. Be prepared and educate the woman and family for this potential outcome.


Anesthesia

Anesthesia poses risks for obese women due to12:

Nov 6, 2018 | Posted by in GYNECOLOGY | Comments Off on Special Considerations for Individualized Care of the Laboring Woman
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