copyright © 2005 by elsevier, inc. all rights reserved. complications of labor and delivery by: ann...

Copyright © 2005 by Elsevier, Inc. All rights reserved.

Complications of Labor and Delivery

by: Ann Hearn RNC, MSNSpring 2009

Complications of Labor and Delivery

by: Ann Hearn RNC, MSNSpring 2009


The PowersThe Powers

Complications • Uterine Dystocia -defined as difficult

labor.– Hypertonic contractions – more

frequent but decreased intensity– Hypotonic contractions – decrease in

frequency (2-3 UC in 10 min period)• Also termed uterine inertia

Complications • Uterine Dystocia -defined as difficult

labor.– Hypertonic contractions – more

frequent but decreased intensity– Hypotonic contractions – decrease in

frequency (2-3 UC in 10 min period)• Also termed uterine inertia


Interventions for Uterine DystociaInterventions for Uterine Dystocia

Hypertonic Uterus: Contractions are painful but ineffective resulting in prolonged latent phase.

• Nursing Interventions:– Bed rest– Sedation or pain relief– Support/educate– Position changes– Comfort measures: calm environment,

music, therapeutic touch, back rub, warm shower, imagery

Hypertonic Uterus: Contractions are painful but ineffective resulting in prolonged latent phase.

• Nursing Interventions:– Bed rest– Sedation or pain relief– Support/educate– Position changes– Comfort measures: calm environment,

music, therapeutic touch, back rub, warm shower, imagery


Interventions for Uterine DystociaInterventions for Uterine Dystocia

Hypotonic Uterus: results from overstretched uterine muscle leading to a prolonged active phase.

• Nursing Interventions:– Amniotomy– Pitocin administration– Emptying bladder– Hydration– Teaching/Support

Hypotonic Uterus: results from overstretched uterine muscle leading to a prolonged active phase.

• Nursing Interventions:– Amniotomy– Pitocin administration– Emptying bladder– Hydration– Teaching/Support


Amniotomy/Artificial Rupture of Membranes (AROM)Amniotomy/Artificial Rupture of Membranes (AROM)

• Advantages:Advantages:– Increases frequency and intensity of uterine

contractions– Release of prostaglandins– Facilitates decent of presenting part– Allows for internal monitoring– Ability to assess amniotic fluid

• Disadvantages:Disadvantages:– Increased risk for infection– Possibility of prolapsed umbilical cord

• Advantages:Advantages:– Increases frequency and intensity of uterine

contractions– Release of prostaglandins– Facilitates decent of presenting part– Allows for internal monitoring– Ability to assess amniotic fluid

• Disadvantages:Disadvantages:– Increased risk for infection– Possibility of prolapsed umbilical cord


Artificial Rupture of MembranesArtificial Rupture of Membranes

Fig. 20-1d


Amniotomy/Artificial Rupture of Membranes (AROM)Amniotomy/Artificial Rupture of Membranes (AROM)

• Nursing careNursing care– Place disposable pads and towel

under-buttock and change frequently– Assess FHR before and after

amniotomy

• Contraindication:Contraindication:**Procedure should not be performed

if head is not engaged**

• Nursing careNursing care– Place disposable pads and towel

under-buttock and change frequently– Assess FHR before and after

amniotomy

• Contraindication:Contraindication:**Procedure should not be performed

if head is not engaged**


Bishop ScoreBishop Score

• Pre-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

• Pre-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 ScoreInduction 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


Pitocin (Oxytocin) AdministrationPitocin (Oxytocin) Administration

Uses of Pitocin:Uses of Pitocin:

• Induction – initiates uterine contractions

• Augmentation – 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

Uses of Pitocin:Uses of Pitocin:

• Induction – initiates uterine contractions

• Augmentation – 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


Indications for Induction (ACOG, 1999) Indications for Induction (ACOG, 1999)

– Diabetes mellitusDiabetes mellitus– Renal diseaseRenal disease– PreeclampsiaPreeclampsia– Premature Premature

rupture of rupture of membranesmembranes

– History of rapid History of rapid laborlabor

– Diabetes mellitusDiabetes mellitus– Renal diseaseRenal disease– PreeclampsiaPreeclampsia– Premature Premature

rupture of rupture of membranesmembranes

– History of rapid History of rapid laborlabor

– ChorioamnionitisChorioamnionitis– Postterm Postterm

gestationgestation– Mild abruptio Mild abruptio

placenta placenta – IUFDIUFD– IUGRIUGR

– ChorioamnionitisChorioamnionitis– Postterm Postterm

gestationgestation– Mild abruptio Mild abruptio

placenta placenta – IUFDIUFD– IUGRIUGR


Pitocin (Oxytocin) AdministrationPitocin (Oxytocin) Administration

• Nursing interventions when titrating Pitocin:– maternal V/S– FHR pattern

• Baseline• Variability• Periodic changes

– Uterine contraction pattern• Frequency • Duration• Interval

• Nursing interventions when titrating Pitocin:– maternal V/S– FHR pattern

• Baseline• Variability• Periodic changes

– Uterine contraction pattern• Frequency • Duration• Interval


Failure to ProgressFailure to Progress

Prolonged Labor

• Causes:– Labor dystocia– Malposition– Malpresentation– Macrosomia

• Interventions:– R/O CPD– Uterine rest– Pitocin augmentation

Prolonged Labor

• Causes:– Labor dystocia– Malposition– Malpresentation– Macrosomia

• Interventions:– R/O CPD– Uterine rest– Pitocin augmentation


Precipitous LaborPrecipitous Labor

Labor < 3 hours

• Complications:– Woman

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

– Fetus • Hypoxia• Cerebral trauma • Pnemothorax

Labor < 3 hours

• Complications:– Woman

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

– Fetus • Hypoxia• Cerebral trauma • Pnemothorax


Precipitous LaborPrecipitous 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?

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?


The PassengerThe Passenger


Malposition of the FetusMalposition of the Fetus

• Medical Treatments:– Rotation and delivery by:

• forceps• vacuum assisted devise

• Medical Treatments:– Rotation and delivery by:

• forceps• vacuum assisted devise


Internal & External Rotation (version)Internal & External Rotation (version)

A procedure performed to change the fetal presentation

• Internal– Podalic- changing the position of the

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

• External– Manual rotation of the fetus from

breech to cephalic presentation via external manipulation of the maternal abdomen

A procedure performed to change the fetal presentation

• Internal– Podalic- changing the position of the

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

• External– Manual rotation of the fetus from

breech to cephalic presentation via external manipulation of the maternal abdomen


External VersionExternal Version

Fig. 20-3


Three MalpresentationsThree Malpresentations

1. Brow: forehead– C/S delivery

2. Face– Vaginal delivery

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

1. Brow: forehead– C/S delivery

2. Face– Vaginal delivery

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


Obstetric Forceps Obstetric Forceps

Fig. 20-4 Middle row


Obstetric Forceps (cont’d)Obstetric Forceps (cont’d)

Fig. 20-4 Last row


Birth Assisted with a Vacuum ExtractorBirth Assisted with a Vacuum Extractor

Fig. 20-5


Cephalo-pelvic DisproportionCPDCephalo-pelvic DisproportionCPD

Fetus is larger than the pelvic diameter

• Hallmark symptom is failure of the fetus to descendCauses: – diseases affecting bones (rickets),

injury– congenital anomolies, pelvic shape &

size

Fetus is larger than the pelvic diameter

• Hallmark symptom is failure of the fetus to descendCauses: – diseases affecting bones (rickets),

injury– congenital anomolies, pelvic shape &

size


Cephalo-pelvic DisproportionCPDCephalo-pelvic DisproportionCPD

• Diagnosis– CT scan– Estimated fetal weight per US

• Trial of labor– Borderline pelvic diameter

• Support patient– Keep the patient informed of progress– Position changes: sitting squatting, hands

& knees may help with descent– Prepare for possible C/S

• Diagnosis– CT scan– Estimated fetal weight per US

• Trial of labor– Borderline pelvic diameter

• Support patient– Keep the patient informed of progress– Position changes: sitting squatting, hands

& knees may help with descent– Prepare for possible C/S


Skin Incisions for Cesarean BirthSkin Incisions for Cesarean Birth

Fig. 20-8


Uterine Incisions for Cesarean BirthUterine Incisions for Cesarean Birth

Fig. 20-9


Vaginal Delivery After Cesarean Section - VBACVaginal Delivery After Cesarean Section - VBAC

Increased risk for uterine rupture

• Obtain informed consent• Nursing Implications

– Large bore IV access– Continuous EFM

Increased risk for uterine rupture

• Obtain informed consent• Nursing Implications

– Large bore IV access– Continuous EFM


Premature Rupture of Membranes - PROMPremature Rupture of Membranes - PROM

Spontaneous rupture of membranes prior to the onset of labor

• Associated conditions:– Infection– Previous history of PROM– Hydramnios– Multiple pregnancy– UTI– Trauma

Spontaneous rupture of membranes prior to the onset of labor

• Associated conditions:– Infection– Previous history of PROM– Hydramnios– Multiple pregnancy– UTI– Trauma



• Determine time of PROM

• Verification of PROM: – Visualization– Sterile speculum exam– pH

• Determine time of PROM

• Verification of PROM: – Visualization– Sterile speculum exam– pH



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

• Administration of Celestone - betamethasone– PPROM: preterm

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

• Administration of Celestone - betamethasone– PPROM: preterm


Preterm LaborPreterm 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

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



• Fetal Fibronectin test– 99% accurate predictor of NO

preterm birth within 7 days

• Nursing Implications– Promote rest, hydration, circulation– Monitor FHR and uterine activity– Administer tocolytics as ordered

• Fetal Fibronectin test– 99% accurate predictor of NO

preterm birth within 7 days

• Nursing Implications– Promote rest, hydration, circulation– Monitor FHR and uterine activity– Administer tocolytics as ordered



TocolyticsTocolytics

• Medications prescribed to stop preterm labor– Terbutaline – B adrenergic receptor

antagonist– Magnesium sulfate – CNS depressant– Ritodrine - not FDA approved for PTL

rarely used.

TocolyticsTocolytics

• Medications prescribed to stop preterm labor– Terbutaline – B adrenergic receptor

antagonist– Magnesium sulfate – CNS depressant– Ritodrine - not FDA approved for PTL

rarely used.


Tocolytic DrugsTocolytic Drugs

Smooth muscle relaxants

Terbutaline Contraindications: hold and notify HCP if maternal HR > 140bpm

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

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

Smooth muscle relaxants

Terbutaline Contraindications: hold and notify HCP if maternal HR > 140bpm

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

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


Ruptured UterusRuptured Uterus

• Causes:– Long difficult labor– Injudicious use of Pitocin– Previous C/S

• Assessment Findings– Fetal bradycardia– Maternal abdominal pain

• Obstetrical Treatment– Emergency Cesarean Section delivery

• Causes:– Long difficult labor– Injudicious use of Pitocin– Previous C/S

• Assessment Findings– Fetal bradycardia– Maternal abdominal pain

• Obstetrical Treatment– Emergency Cesarean Section delivery


Uterine RuptureUterine Rupture


Prolapsed Umbilical CordProlapsed 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 Interventions– Knee chest position– Administer O2– Manual lift of fetal head off the 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


Variations of Prolapsed Umbilical CordVariations of Prolapsed Umbilical Cord

Fig. 27-6a


Variations of Prolapsed Umbilical Cord (cont’d)Variations of Prolapsed Umbilical Cord (cont’d)

Fig. 27-6c


Amniotic Fluid EmbolismAmniotic Fluid EmbolismIn 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

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 EmbolismAmniotic Fluid Embolism

Assessment Findings: Sudden onset• Respiratory distress (dyspnia)

• Circulatory collapse (cyanosis)

• Tachycardia

• Hypotension

• Acute hemorrhage

• Cor Pulmonale

• Frothy sputum

Assessment Findings: Sudden onset• Respiratory distress (dyspnia)

• Circulatory collapse (cyanosis)

• Tachycardia

• Hypotension

• Acute hemorrhage

• Cor Pulmonale

• Frothy sputum


Amniotic Fluid EmbolismAmniotic Fluid Embolism

Obstetrical Emergency

• Interventions:– Large bore IV line– Positive pressure oxygen– CPR– Blood transfusion - DIC– Emergency C/S if pregnant

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

Obstetrical Emergency

• Interventions:– Large bore IV line– Positive pressure oxygen– CPR– Blood transfusion - DIC– Emergency C/S if pregnant

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

copyright © 2005 by elsevier, inc. all rights reserved. complications of labor and delivery by: ann...

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