labor and delivery complications-1

8/8/2019 Labor and Delivery Complications-1

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Labor and DeliveryComplications

Binnece J. Green MSN APNC

www.avc.edu.


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Complications due to Anxiety and Fear

Individuals ineffective coping

Ineffective family coping and

expectations Fear of pain

Fear of change in family dynamics

Fear due to educational deficit Support systems


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Anxiety and Fear

Support the laboring woman

Education

Modeling and relaxation techniques

Support partner in relaxationtechniques, and maintaining control

Establish confident rapport


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Abnormal Laboring

Abnormal labor attributed to threefactors:

inefficient uterine action persistent posterior presentation

cephalopelvic disproportion


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Dystocia

Uterine contractions

normal: occur regularly

2 to 4 contractions per 10 minutes. mean applitude 35mmHG in early

labor

progresses to:

4 to 5 contractions per 10 minutes

mean amplitude 40-50mmHG


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Dystocia

Dysfunctional : contractions areirregular, low amplitude, slow

Progress, cervical dilations slow orarrested.

Interventions by physician

evaluate size of maternal pelvis position and presentation fetus

fetal weight


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Dystocia continued

Do not give Oxytocin (Pitocin) ifwoman has cephalopelvic

dysproportion. (CPD) If no CPD, amniotomy, Pitocin

(1mU/min): goal is to obtain 8contractions per 20 minutes.

Assess vs, contractions, dilation,decent, fetal ht. rate


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Dystocia Continued

Encourage changing position

Ambulation

Warm Showers Relaxation (visualization)

Mouth care

Encourage Voiding Nipple stimulation


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Umbilical Cord Prolapse

Etiology 1-275 deliveries

Definition: umbilical cord that lies below/besidepresenting part

Usually immature gestation

Results in fetal hypoxia & death

> 5 min results in CNS damage/ death


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Precipitatingfactors:

Long umbilical cord

Abnormal locationon placenta

Small or preterminfant

Polyhydramnios Multiple gestation

Amniotomy beforefetal head isengaged


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Clinical Manifestations:

Cord observed or palpated

Bradycardia following ROM Repetitive, variable decelerations that

do not respond to medical intervention

Prolonged decelerations (>15 bpm

lasting 2 mins or longer yet


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Nursing interventions:

Apply gentle upward pressure on presentingpart

Knee chest position Medical management:

Immediate delivery of viable infant

C-section


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Shoulder Dystocia

Etiology

Occurs in approx. 0.15-2.0% of all NSVDs

When the anterior shoulder does not fit under

the pubic arch.

Cephalic presentation: head has beendelivered by extension problem with externalrotation (shoulders unable to be delivered)

Highly associated with macrosomic infants (>4000gms)


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Shoulder Dystocia

Clinical Manifestation: Turtle sign

Head presents on perineum and then

retracts Other signs and symptoms during

labor

Excessive molding

Prolonged fetal rate of descent(


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Shoulder Dystocia

Nursing interventions: OB emergency

Assist with positioning to expand pelvic space

for delivery of infant Woods maneuver

McRoberts maneuver

Stop maternal pushing

Call for assistance

Lower bed Empty bladder via catheterization


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Shoulder Dystocia

Nursing Interventions: Anticipate fetal complications

Erbs Palsy: (brachial plexus palsy)

Facial paralysis Respiratory depression

Fractured clavicle

Anticipate maternal complications:

Early postpartum hemorrhage r/t uterine atony

Hematomas (cervical/uterine/vaginal)

Hematuria

Infection

Hypovolemia


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Meconium Stained Amniotic Fluid

Appearance of meconium in AF

Staining r/t amount of meconium passed in

utero

Vernix stains yellow within 12-14 hours ofexposure

Fetal fingernails stain yellow within 4-6 hours

of exposure

Placental surface stains within 3 hours

Umbilical cord stains within 1 hour


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Observe amount, color, odor of AF

Report to CNM, MD Amnioinfusion

1000cc NS at room temperature/ bloodwarmer esp. if preterm

Bolus of 200-250 ml over 20 minutes; then100cc/hr

Monitor FHR, uterine activity and restingtone


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Prepare Labor and delivery room

Anticipate fetal respiratory depression at delivery

Notify neonatal team: will gentleoropharyngeal/nasopharyngeal suctioning withmechanical suctioning of head on the perineum

Laryngoscopy; tracheal intubation and suctioning fordepressed infants


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Amniotic Fluid Embolism

Etiology: 1-80,000 deliveries

Maternal mortality rate of approx. 86%

Short interval between onset and death 10 minutes-32 hours

One quarter of the clients die r/t

cardiopulmonary arrest within 1 hour 50% of survivors develop acute DIC within 30

mins- 4 hours

No known risk factors


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Clinical Manifestations:Medical Emergency

Respiratory: Dyspnea Acute cyanosis

Pink,frothy sputum

No chest pain

CNS: Convulsions

Apprehension

Extreme anxiety


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Clinical Manifestations:MedicalEmergency

Cardiovascular:

Hypotension

Sudden,profound shock

dysrhythmias


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Medical Management:

CPR prn

Oxygen at high concentrations

Rapid volume infusion; dopamine infusion ifindicated

Fresh whole blood or packed RBCs, andfresh plasma to treat bleeding r/t DIC

Lab studies:CBC,PT,PTT, Liver enzymes,fibrinogen, platelet count


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Hydramnios

Occurs when >2000ml of amnioticfluid.

1% all pregnancies Unknown cause but is seen in

conjunction with major congenitalanomalies

Types: Chronic

Acute


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Hydramnios

Chronic : fluid gradually rises,becomes problem 3rd trimester

Acute: rapid increase over days Often diagnosed between 20-24

wks.

>3000ml Sx. Shortness breath

edema

pain


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Hydramnios (cont)

Maternal disorders

Diabetics

RH sensitization

Infection ex. CMV, syphilis Treatment

supportive

If severe hospitalization, removal

fluid through AROM or amnio.

Indomethacin shown to decrease amniotic fluid by decreasing fetal urine

output.


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Oligohydramnios

Less than normal amount ofamniotic fluid

norm is 500ml. Unknown cause

Found in cases of postmaturity withintrauterine growth restriction

secondary placental insufficiency Fetal conditions: renal

malformations


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Oligohydramnios (cont.)

Concern with fetal adhesions

One part of fetus adhere to another

Fetal skin and skeletal abnormalitiesDue to decrease in fetal movement

Pulmonary: pulmonary hypoplasia

Complications in birthing process dueto decrease fluid for cushioning


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Oligohydramnios (cont.)

Monitor uterine growth (suspect if uterusdoesnt increase in size.

Fetus easily palpated

Fetus not ballottable (fetus floats awayand returns when pushed)

Monitor cord compression due to decreasecushioning during birth

Fetal monitoring Amniofusion: infuse sterile

fluid(NS)through intrauterine catheter


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Placental Complications

Abruptio Placentae

Premature separation of placenta(prior to 3rd stage labor)

Source- maternal from uterinesurface

More common with HX HTN,multiparas->5

Lower socioeconomic


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Abruptio Placentae: symptoms

Severe pain

Fetal distress

Dark bleeding Rigid abdomen

Sx shock


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Management

L lateral recumbant

O2 100%

IV Assess for Coagulation

abnormalities

Monitor mother and fetus


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Placenta Previa

Placenta implanted in lower regionof uterus

Placenta precedes fetus More common multiparas

Source- maternal

Placenta usually larger


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Placenta Previa Symptoms

Painless

Vaginal bleeding

Bleeding bright red Bleeding may not begin until labor

begins


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Management

No vaginal exam

HOB 20-30 degrees

100% O2 IV

Monitor mother and fetus


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Breech Presentation

4% births

Gestational age 25-26weeks

incidence increases to 25% Frank Breech most common

Often associated with placentaprevia, hydramnios, multiplegestation, fetal anomalies

Cord prolapse more common


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Cesarean Births

Indications:Dystocia

Cephlopelvic disproportion

Maternal disease as diabetes Active genital herpes

Benefit of the FetusMalpresentations; multiple gestation

Placental abnormalitiesCord Prolapse

Emergency conditions


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Breech Presentation (cont.)

Cesarean birth preferred due to increasein mortality and morbidity rate due tocord prolapse, birth trauma, fetal cervical

trauma. Contraindications for vaginal birth

fetal weight less than 1500g

hyperextention of fetal neck of

more than 90 degrees anomalies ie hydrocephalus

maternal pelvic measurements


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Cesarean Risks

Maternal:

Infection

Hemorrhage

Urinary tracttrauma

Thrombophlebitis

Atelectasis Aspiration

Fetal:

Inadvertantpreterm birth

Transient tacypnea

Persistentpulmonaryhypertension

Injury aslaceration


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Care During Aversion

A procedure used to change thefetal presentation by abdominal or

Intrauterine manipulation External version

May be very painful


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Cesarean Birth (cont.)

Surgical techniques:

Vertical vs. Horizontal incisions

Maternal Risks: Aspiration, PE,Infections, thrombophlebitis,injuries, risks related to anesthesia,emotional trauma

Fetal Risks: Prematurity, injury,respiratory distress


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Nursing Management

Provide emotional support

Use therapeutic communication topromote positive childbirth experience

Stress management techniques

Support person should be encouraged toremain with her during the birth

Provide teaching r/t cesarean experience


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Nursing Considerations

Preoperative care: VS, FHR,Retention Catheter, Informed

consent, shaving,IV fluids, removalof jewelry, or attachments

Assess emotional preparation of

both woman in labor and supportpersons


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Birth Related Interventions

Amniotomy

Prostagalandin Administration

Misoprostol Administration Induction of Labor

Amniofusion

Episiotomy

Forceps-Assisted Birth

Cesarean Birth


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Precipitous Delivery

Precipitous labor is on the other end of

the spectrum of labor abnormalities >5cm/hr dilatation in nullips; >10cm/hr

in multips

Complications of precipitous labor include

trauma to birth canal; fetal distress; andpostpartum hemorrhage

labor and delivery complications-1

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