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C H A P T E R

17Labor and Birth Complications

K E Y P O I N T S

•  Preterm labor consists of uterine contractions with cervical

change (e.g., effacement and dilation) that occur between 20 and

37 completed weeks of pregnancy ; preterm birth is any birth thatoccurs before the completion of 37 weeks of pregnancy.

•  Complications related to preterm birth account for more

newborn and infant deaths than any other cause.

•  The incidence of preterm birth in the United States varies con-

siderably by race.

•  Preterm birth describes length of gestation, whereas low birth

weight describes only weight at the time of birth.

•  Preterm birth is divided into two categories: spontaneous and

indicated. Spontaneous preterm birth occurs after an early initia-

tion of the labor process and comprises nearly 75% of all preterm

births in the United States. Indicated preterm birth occurs as a

means to resolve maternal or fetal risk related to continuing the

pregnancy.

•  The cause of preterm labor is unknown and is assumed to be

multifactorial.

•  Preconception counseling and care for women, especially those

with a history of preterm birth, may identify correctable riskfactors and provide a means to encourage women to participate

in health-promoting activities.

•  Because the onset of preterm labor can often be mistaken for

normal discomforts of pregnancy, nurses should teach all preg-

nant women how to detect the early symptoms of preterm labor

and to call their primary health care provider when symptoms

occur.

•  Bed rest, still a commonly prescribed intervention for preterm

labor, has many deleterious side effects and has never been

shown to decrease preterm birth rates; modified bed rest is

recommended.

•  The best reason to use tocolytic therapy is to achieve sufficient

time to administer glucocorticoids in an effort to accelerate fetal

lung maturity and reduce the severity of respiratory complica-

tions in infants born preterm. In addition, time is allowed for

transport of the woman before birth to a center equipped to care

for preterm infants.•  When preterm birth appears inevitable, magnesium sulfate may

be administered to reduce or prevent neonatal neurologic

morbidity 

•  If fetal or early neonatal death is expected, the parents and

members of the health care team need to discuss the situation

before the birth and decide on a management p lan that is accept-

able to everyone.

•  Premature rupture of membranes (PROM) is the spontaneousrupture of the amniotic sac and leakage of amniotic fluid begin-

ning before the onset of labor at any gestational age. Preterm

premature rupture of membranes is associated with approxi-

mately 10% of all preterm births in the United States.

•  Vigilance for signs of infection is an essential part of the care for

women with preterm PROM.

•  A postterm pregnancy poses a risk to both the mother and the

fetus.

•  Dysfunctional labor results from differences in the normal rela-

tionships among any of the five factors affecting labor and is

characterized by differences in the pattern of progress in labor.

•  Malpresentation (the fetal presentation is something other than

cephalic or head first) is another commonly reported complica-

tion of labor and birth. Breech presentation is the most common

form.

•  Obese women are at risk for several complications during labor

and birth, including cesarean birth. Even routine proceduresrequire more time and effort to accomplish when the woman is

obese.

•  Labor should not be induced electively until the woman has

reached at least 39 weeks of gestation.

•  Cervical ripening using chemical or mechanical measures can

increase the success of labor induction.

•  Amniotic membrane stripping or sweeping is a method of induc-

ing labor through the release of prostaglandins and oxytocin.

•  Oxytocin is a hormone normally produced by the posterior pitu-

itary gland. It stimulates uterine contractions and aids in milk

let-down. Synthetic oxytocin (Pitocin) may be used either to

induce labor or to augment a labor that is progressing slowly

because of inadequate uterine contractions.

•  Expectant parents benefit from learning about operative obstet-

rics (e.g., forceps- or vacuum-assisted or cesarean birth) during

the prenatal period.

•  Maternal indications for forceps-assisted birth include a pro-longed second stage of labor and the need to shorten the second

stage of labor for maternal reasons. Fetal indications include

an abnormal FHR tracing or certain abnormal presentations,

arrest of rotation, or extraction of the head in a breech

presentation.

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UNIT 4  Childbirthe20

•  Vacuum-assisted birth is a birth method involving the attach-

ment of a vacuum cup to the fetal head, using negative pressure

to assist in the birth of the head. It is generally not used to assist

birth before 34 weeks of gestation. Indications for its use are the

same as those for outlet forceps. Prerequisites for use include a

completely dilated cervix, ruptured membranes, engaged head,

vertex presentation, and no suspicion of CPD.

•  The basic purpose of cesarean birth is to preserve the life and

health of the mother and her fetus.

•  Possible maternal complications related to cesarean birth include

aspiration, hemorrhage, atelectasis, endometritis, abdominal

wound dehiscence or infection, urinary tract infection, injuries to

the bladder or bowel, and complications related to anesthesia.

•  The attitude of the nurse and other health care team members

can influence the woman’s perception of herself after a cesarean

birth. The caregivers should stress that the woman is a new

mother first and a surgical patient second.

•  Unless contraindicated, a vaginal birth may be possible after a

previous cesarean birth. A trial of labor (TOL) is the observance

of a woman and her fetus for a reasonable period of spontaneous

active labor to assess the safety of vaginal birth for the mother

and infant. It may be initiated if the mother’s pelvis is of ques-

tionable size or shape or if the fetus is in an abnormal presenta-tion or position. By far the most common reason for a TOL is if

the woman wishes to have a vaginal birth after a previous cesar-

ean birth.

•  Labor management that emphasizes one-on-one support of the

laboring woman by another woman (doula, nurse, or nurse-

midwife) can reduce the rate of cesarean birth and increase the

VBAC rate.

•  The major risk associated with meconium-stained amniotic fluid

is the development of meconium aspiration syndrome (MAS) in

the newborn. The presence of a team skilled in neonatal resus-

citation is required at the birth of any infant with meconium-

stained amniotic fluid.

•  Shoulder dystocia is an uncommon obstetric emergency that

increases the risk for fetal and maternal morbidity and mortality

during the attempt to accomplish birth vaginally.

•  Umbilical cord prolapse may be occult (hidden, rather than

visible) at any time during labor, whether or not the membranes

are ruptured. It is most common to see frank prolapse directly

after rupture of membranes. Contributing factors include a long

cord, malpresentation, or an unengaged presenting part. Prompt

recognition of a prolapsed umbilical cord is very important.

•  During labor and birth, the major risk factor for uterine rupture

is a scarred uterus as a result of previous cesarean birth or other

uterine surgery. Prevention is the best treatment.

•  Amniotic fluid embolus (AFE) is a rare but devastating compli-

cation of pregnancy characterized by the sudden, acute onset ofhypoxia, hypotension, cardiovascular collapse, and coagulopathy.

Care must be instituted immediately. Cardiopulmonary resusci-

tation is often necessary.

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