Complications of Labor and Delivery

by: Ann Hearn, MSN, RNC

Complications of Labor and Delivery

by: Ann Hearn, MSN, RNC

The PowersIneffective ContractionsUterine Dystocia -defined as difficult labor.

Hypotonic contractions – coordinated, infrequent, weak, brief, mildly painful.

Hypertonic contractions – uncoordinated and erratic in frequency, duration and intensity; Painful.

Interventions for Uterine DystociaHypotonic Uterus: results from overstretched

uterine muscle leading to a prolonged active phase.

Nursing Interventions:Position changes, ambulationEmptying bladderAmniotomyPitocin administrationHydrationTeaching/Support

Interventions for Uterine DystociaHypertonic Uterus: Contractions are painful

but ineffective resulting in prolonged latent phase.

Nursing Interventions:Bed restSedation or pain reliefPosition changesSupport/educateComfort measures: calm environment, music,

therapeutic touch, back rub, warm shower, imagery

Ineffective Pushing.If pushing is ineffective, correct the cause.

Incorrect techniquesFear of injuryMinimal or no urgeMaternal exhaustionRegion block Psychological unreadiness

There is no time limit for 2nd Stage

The Passenger

Problems with the PassengerFetal Size

Shoulder dystociaPresentation

Fetal liePosition

Assisted deliveryMulti-fetalFetal anomalies

Three Malpresentations1. Brow: forehead

C/S delivery

2. Face Vaginal delivery

3. Breech• Frank – buttocks• Footling – foot/feet C/S delivery

The Passage WayPelvis

Size & shapeBladder

The PsychePainStressFearNon-support

Failure to ProgressProlonged LaborCauses:

Labor dystociaMalpositionMalpresentationMacrosomia

Interventions:R/O CPDUterine restPitocin augmentation

Friedman’s Curve

Precipitous LaborLabor < 3 hours from onsetComplications:

Woman loss of coping ability Lacerations of cervix, vagina, perineum

Fetus Hypoxia Cerebral trauma Pnemothorax

Precipitous LaborMonica, a G1, P0 @ 39.4wks is admitted to L&D with

occasional uterine contractions that started soon after her BOW broke an hour ago. She pauses during conversation to breath during contractions and gives a pain rating of 5. Monica states she will probably want an epidural.

While performing the admission history/assessment you notice that Monica’s contractions are occurring every 2 minutes and palpate strong. Monica is beginning to demonstrate difficulty with coping during contractions. Monica grunts during her last contraction.

What nursing interventions will you provide?

Nursing Care in Dysfunctional Laborintrauterine infection

Identify s/sReduce risk

Assist with exhaustionConserve energyPromote coping skills

Premature Rupture of Membranes - PROMSpontaneous rupture of membranes prior to

the onset of laborAssociated conditions:

InfectionPrevious history of PROMHydramniosMultiple pregnancyUTITrauma

Premature Rupture of Membranes - PROMDetermine time of PROMVerification of PROM:

VisualizationSterile speculum exampH

Premature Rupture of Membranes - PROMNursing Assessment

Vital signs (temp q 2hr)Fetal monitoringNature of fluidWBC count

PPROM: PretermCelestone - betamethasoneAntibiotics

If leak seals, discharge instructions

Preterm LaborDefined as: labor that occurs between 20 and

37 weeks gestation.Associated conditions

Multiple gestationHydraminosUTIAbdominal traumaInfectionNo prenatal careLow socio-economic status

Preterm LaborPrevention of PTL

Education Diagnosing PTL:

Fetal Fibronectin test (fFN) 99% accurate predictor of NO preterm birth within

7 days

Preterm LaborTocolytics: Tocolytics: Medications prescribed to stop preterm labor

Magnesium sulfate – CNS depressantNifedipine – Calcium channel blockerIndomethacin – Prostaglandin synthesis

inhibitorTerbutaline – B adrenergic receptor agonist

Tocolytic Drugs - Smooth Muscle Relaxants. Magnesium Sulfate Contraindications: discontinue for resp. depression, magnesium level >8, administer ca+ gluconate

Side Effects: flushing, headache, nausea, lethargy, dizziness, decreased DTR, decreased resp. rate, pulmonary edema

Nifedipine Contraindications: kidney or liver disease (especially cirrhosis), coronary artery disease, congestive heart failure, or digestive problems

Side Effects: flushing, headache, orthostatic hypotension, transient maternal/fetal tachycardia

Terbutaline Contraindications: hold and notify HCP if mat. HR > 120bpm

Side effects: increase heart rate, feeling of anxiety, headache, increased blood glucose

Indomethacin Contraindications: given X48-72 hoursSide effects: constriction of PDA, prolong bleeding, N/V, heartburn,

rash

Nursing Management for the Woman in Preterm Labor

Nursing ImplicationsPromote rest, hydration, circulationMonitor FHR and uterine activity

SupportMedical therapy

TocolyticsSteriodsAntibiotic

Adherence to therapy

Prolapsed Umbilical CordOccurs when the umbilical cord precedes the

presenting part.Primary Risk Factor

Fetal head is not engaged or at a high station

Vessels carrying blood to & from the fetus are compressed, usually results in fetal distress or possible demise

Nursing InterventionsKnee chest positionAdminister O2Manual lift of fetal head off the cord

Variations of Prolapsed Umbilical Cord

Fig. 27-6a

Variations of Prolapsed Umbilical Cord (cont’d)

Fig. 27-6c

Ruptured UterusCauses:

Long difficult laborInjudicious use of PitocinPrevious C/S

Assessment FindingsFetal bradycardiaMaternal abdominal pain

Obstetrical TreatmentEmergency Cesarean Section delivery

Uterine Rupture

Anaphylactoid Syndrome: Amniotic Fluid Embolism

In the presence of a small tear in the amnion and chorion, a small amount of amniotic fluid may leak into the chorionic plate and enter the maternal blood system.

Can also occurs at areas of placental separation, cervical tears or during trumultuous labor

The more debris (meconium, vernix, lanugo) in the amnionic fluid, the greater the maternal problems caused by possible anaphylactic reaction to fetal antigens

Amniotic Fluid EmbolismAssessment Findings: Sudden onsetRespiratory distress (dyspnia)Circulatory collapse (cyanosis)TachycardiaHypotension Acute hemorrhageCor PulmonaleFrothy sputum

Amniotic Fluid EmbolismObstetrical EmergencyInterventions:

Large bore IV linePositive pressure oxygenCPRBlood transfusion - DICEmergency C/S if pregnant

Prognosis – 50% of women die with the first hour of symptoms

Amniotomy/Artificial Rupture of Membranes (AROM)

Advantages:Advantages:Increases frequency and intensity of uterine

contractionsRelease of prostaglandinsFacilitates decent of presenting partAllows for internal monitoringAbility to assess amniotic fluid

Disadvantages:Disadvantages:Increased risk for infectionPossibility of prolapsed umbilical cord

Artificial Rupture of Membranes

Fig. 20-1d

Amniotomy/Artificial Rupture of Membranes (AROM)Nursing careNursing care

Place disposable pads and towel under-buttock and change frequently

Assess FHR before and after amniotomyDocument: color, clarity, odor

Contraindication:Contraindication:**Procedure should not be performed if head is

not engaged**

Indications for Induction (ACOG, 1999)

Medical ConditionsDiabetes mellitusRenal diseaseChronic HTN

PreeclampsiaPremature

rupture of membranes

ChorioamnionitisPostterm

gestationMild abruptio

placenta IUFDIUGR

Induction/Augmentation of LaborArtificial methods to stimulate uterine

contractions.Induction: Initiation of labor

Medical Elective

Augmentation: Improve quality of contractions

Bishop ScorePre-labor status evaluation scoring system

A predictor for the potential success of induction of labor

A high score indicates the cervix is favorable and vaginal delivery will likely occur

Induction of LaborBishop Score

Score 0 1 2 3Dilation <1cm 1-2cm 2-4cm >4cmEffacement

0-30% 40-50% 60-70% 80%

Fetal Station

-3 -2 -1, 0 +1, +2

Cervical Consistency

Firm Intermediate

Soft

Cervical Position

Posterior Intermediate

Anterior

Cervical RipeningProstaglandin E2 preparations

Prepidil 2.5mg – gelCervidil 10mg – insert on stringCytotec 25mcg - pill

Pitocin (Oxytocin) AdministrationUses of Pitocin:Uses of Pitocin:Induction – initiates uterine contractionsAugmentation – enhances ineffective

contraction pattern

Goal:Goal:A labor pattern with uterine contractions occurring every 2-3 minutes, lasting 40-60 seconds and a return to baseline between contractions

Pitocin (Oxytocin) AdministrationNursing interventions when titrating Pitocin:

Maternal V/SFHR pattern

Baseline Variability Periodic changes

Uterine contraction pattern Frequency Duration Interval

External Version

Fig. 20-3

Internal & External Rotation (version)A procedure performed to change the fetal

presentation Internal

Changing the position of the 2nd twin after delivery of the 1st via vaginal manipulation

ExternalManual rotation of the fetus from breech to

cephalic presentation via external manipulation of the maternal abdomen

External Version: Nursing ManagementPre Procedure:Admission process

Consent for procedure & delivery

V/S & EFMIV accessTocolyticUltrasound

Post Procedure:V/S & EFMPresences of

contraction - LaborRhogam if Rh –S/S abruptio

placentaeRupture of

membranes

Obstetric Forceps

Fig. 20-4 Middle row

Obstetric Forceps (cont’d)

Fig. 20-4 Last row

Birth Assisted with a Vacuum Extractor

Fig. 20-5

EpisiotomyIncision of the perineum just before birth.Indications:

Shoulder dystociaAssisted delivery (forceps/vacuum)OP position

Midline or Mediolateral* Laboring down, perineal massage, pushing in the upright position reduce the incidence of episiotomy.

Cesarean BirthIndicationsRisks

MaternalInfant

Pre-operative care & prepIV hydration/prophylactic antibioticsAnesthesia: epidural/spinalFHRFoley/shave & skin prepTime-out

Skin Incisions for Cesarean Birth

Fig. 20-8

Uterine Incisions for Cesarean Birth

Fig. 20-9

Cesarean Birth: Recovery CareV/S, respirations, O2 sats, ECGLOCAbdominal dressingFundus/LochiaUrinary output/ IV fluidsSensation/movement lower extremitiesPain scaleBonding with infant

Vaginal Delivery After Cesarean Section - VBACIndications:

Previous low transverse uterine incisionNo more than 2 previous C/S

Obtain informed consentNursing Implications

Large bore IV accessContinuous EFM** Increased risk for uterine rupture