Complications of Labor & Delivery

Fall 2012

Dysfunctional Labor

Normal labor is characterized by progress.

Dystocia is a general term that applies to any difficult labor or birth.

Causes› The Powers› The Passenger› The Passageway› The Psyche

Complications of The Powers

Ineffective uterine contractions› Uterine Dystocia

Hypertonic Contractions Hypotonic Contractions

Ineffective Maternal Pushing

Uterine Dystocia

Hypotonic contractions› Weak › Infrequent› Short› Pt comfortable

Nursing interventions› Walking › Position changes› Amniotomy› Oxytocin

Hypertonic Contractions› Uncoordinated and eratic› Painful but ineffective› Usually occurs in latent phase› High resting tone› Maternal fatigue

Nursing interventions› Pain management› Promote relaxation› Analgesics› Oxytocin or amniotomy› Tocolytics may be ordered

Ineffective Pushing

Incorrect technique Fear Decreased urge Exhaustion

Complications of the Passenger

Fetal Size Malpositions Malpresentations Multifetal pregnancy Fetal Anomalies

Interventions

Vacuum extraction Forcep delivery

› Risks of both to the baby› Risks of both to the mother

Complications of the Passageway

Pelvis› Pelvic Dystocia (Cephalopelvic

Disproportion) Bladder

Interventions

Monica, 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?

Problems of the Psyche

Pain Stress Fear Support

Abnormal Labor Duration

Prolonged Labor› Once in active

phase should proceed at 1-2 cm/hr

› Risk Factors› Nursing

interventions

Precipitous Labor› Birth that occurs

within 3 hours of the onset of labor

› Causes› Nursing

interventions

Premature Rupture of Membranes

Spontaneous rupture of membranes prior to the onset of labor

Associated conditions:› Infection

STDs, UTI, GBS› Previous history of PROM› Amniotic sac with a weak structure› Fetal abnormalities› Overdistention of the urterus› Maternal stress› Trauma

Premature Rupture of Membranes (PROM)Determine time of PROMVerification of PROM:

• Visualization• Sterile speculum

exam for ferning• pH

Nursing Assessment› Vital signs (temp q 2hr)› Fetal monitoring› Nature of fluid› WBC count

Administration of Celestone - betamethasone› PROM: preterm

If leak seals, discharge instructions

Preterm Labor

Defined as: labor that occurs between 20 and 37 weeks gestation.

Associated conditions› Multiple gestation› Hydraminos› UTI› Abdominal trauma› Infection› No prenatal care› Low socio-economic status

Cervical Length Fetal Fibronectin test

› 99% accurate predictor of NO preterm birth within 7 day

Infections

Preventing Preterm Birth

Treat the underlying cause› Preeclampsia› Hypovolemia› Serious Infection

Promote rest Hydration

Medications

Tocolytics Medications prescribed to stop preterm

labor› Terbutaline – B adrenergic receptor agonist› Indomethacin- Prostaglandin inhibitor› Magnesium sulfate – CNS depressant› Nifedipine - Calcium channel blocker

Accelerating Fetal Lung Maturity

Necessary if infant < 34 weeks (24-34 weeks)

Betamethasone› Every 7 days› Birth should be delayed by 24 hours

Intrapartum Emergencies

Prolapsed Umbilical Cord

Occurs 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 Interventions› Knee chest position› Administer O2› Manual lift of fetal head off the cord

Prolapsed Umbilical Cord

Ruptured Uterus

Causes:› Long difficult labor› Injudicious use of Pitocin› Dehisence› High parity› Blunt abdominal trauma

Manifestations

Pain Chest pain Hypovolemic shock Impaired fetal oxygenation Absent fetal heart sounds Cessation of uterine contractions Palpation of fetus

Nursing considerations

Identify the risks Use oxytocin cautiously Monitor bleeding

Ruptured Uterus

Anaphylactoid Syndrome(Amniotic Fluid Embolus)

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

Assessment Findings: Sudden onset Respiratory distress (dyspnea) Circulatory collapse (cyanosis)

› First the right ventricle, then left Tachycardia Hypotension Acute hemorrhage

› DIC

Obstetrical Emergency Interventions:

› CPR› Mechanical ventilation› Correction of hypotension› Blood transfusion - DIC› Emergency C/S if pregnant

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