Complications
of
Labor and Delivery
Presented by
Jeanie Ward
Dystocia
An abnormal, long, or
difficult labor or delivery
Dysfunctional Labor is related to
Abnormalities of the Critical Factors:
PASSAGEWAY
PSYCHE
Critical
Factors
PASSENGER
POWERS
UTERINE DYSTOCIA
DYSFUNCTIONAL UTERINE CONTRACTIONS
HYPOTONIC UTERINE CONTRACTIONS
UTERINE INERTIA
• Etiology and Pathophysiology:
– Overstretching of the uterus --large baby,
multiple babies, polyhydramnios, multiple
parity
– Bowel or bladder distention preventing
descent
– Excessive use of analgesia
ASSESSMENT
• Signs and Symptoms of HYPOTONIC
UTERINE INERTIA:
– Weak contractions – become mild
– Infrequent (every 10 – 15 minutes +) and
brief,
– Can be easily indented with fingertip
pressure at peak of contraction.
– Prolonged ACTIVE Phase
– Exhaustion of the mother
– Psychological trauma - frustrated
Friedman’s Graph
Hypotonic Uterine Contractions
Normal
Curve
Prolonged active phase
Therapeutic Interventions
– Ambulation
– Nipple Stimulation --release of endogenous
Pitocin
– Enema--warmth of enema may stimulate
contractions
– Amniotomy--artificial rupture of the
membranes
– Augmentation of labor with Pitocin
Amniotomy
• Amniotomy is the artificial rupture of the amniotic
sac with a tool called the amniohook (a long
crochet type hook, with a pricked end) or an
amnicot (a glove with a small pricked end on one
finger).
• One of these will be placed inside the vagina,
where the caregiver will rupture the amniotic sac
or membrane.
AMNIOTOMY
• Advantages of doing this before Pitocin
– Contractions are more similar to those of
spontaneous labor
– Usually no risk of rupture of the uterus
– Does not require as close surveillance
• Disadvantages of an Amniotomy
– Delivery must occur
– Increase danger of prolapse of umbilical cord
– Compression and molding of the fetal head (caput)
Amniotomy
• Nursing Care:
–
–
–
–
–
# 1-Check the fetal heart tones
Assess color, odor, amount
Provide with perineal care
Monitor contractions
Check temperature every 2 hours
Answer
Cervical Ripening
Cervical Ripening
• prostaglandin E2 Medications
– Prepidil gel
– Cervodil
• Prostaglandin E1 Medication
– Cytotec
• Nursing Care
– Monitor maternal vital signs, cervical dilatation and
effacement
– Monitor fetal status for presence of reassuring fetal
heart rate
– Remove medication if hyperstimulation occurs
Hyperstimulation
• Remove the medication
• Turn patient to side-lying position
• Provide oxygen via face mask
• Give Terbutaline
PITOCIN
Augmentation of Labor
• Assess first to make sure CPD is not present,
then start procedure:
– Give 10 units / 1000 cc. fluid and hang as a secondary
infusion, never as primary
• Nursing Care:
–
–
–
–
Assess contractions--are they increasing but not tetanic
Assess dilation and effacement
Monitor vital signs and FHT’s
Make sure no signs of hyperstimulation before
increasing dose
HYPERTONIC UTERINE
CONTRACTIONS
• Most often occur in first-time mothers,
Primigravidas
• Contractions are ineffectual, erratic,
uncoordinated, and of poor quality that
involve only a portion of the uterus
• Increase in frequency of contractions, but
intensity is decreased, do not bring about
dilation and effacement of the cervix.
Signs and Symptoms
– PAINFUL contractions RT uterine muscle
anoxia, causing constant cramping pain
– Dilation and effacement of the cervix does not
occur.
– Prolonged latent phase. Stay at 2 - 3 cm. don’t
dilate as should
– Fetal distress occurs early– uterine resting
tone is high, decreasing placental perfusion.
– Anxious and discouraged
Friedman’s Graph
Hypertonic Uterine Contractions
Prolonged latent
phase
Relieve pain and promote
normal labor pattern
Treatment of Hypertonic
Uterine Contractions
• Provide with COMFORT MEASURES
Warm shower
Mouth Care
Imagery
Music
Back rub, therapeutic touch
•
•
•
•
Mild sedation
Bedrest or position changes
Hydration
Tocolytics to reduce high uterine tone
Ineffective Maternal Pushing
• Results from:
– Incorrect pushing techniques
– Fear of injury
– Decreased urge to push
– Maternal exhaustion
• Treatment
– Teaching
Complication
of the
Passenger
Fetal Size
• Macrosomia
– Infant weighs more than 8 lb. 13 oz.
– Shoulder dystocia
• McRoberts maneuver
• Suprapubic pressure
Abnormal Presentation and
Positions
• Malpositions:
– Posterior position--usually mom complains of
back pain
• Malpresentation
Brow Face -
Breech -
Transverse -
Problems of Passenger
• Cephalopelvic Disproportion (CPD)
– Large baby or small pelvis
– Usually diagnosed when there is an arrest in
descent
– Station remains the same
• Multiple Fetus
– Twins, triplets, etc.
Treatments for Complications of
the Passenger
– Positioning – hands and knees, lunge to side
– Version -- alteration of fetal position by abdominal
or intrauterine manipulation
– Amnioinfusion - infusion into the uterine cavity
– Forceps -- low forceps or outlet forceps usually
applied after crowning
– Vacuum extraction -- disk shaped cup placed over
vertex of head and vacuum applied.
– Episiotomy - surgical incision to allow more room
– Cesarean Delivery
External Version Procedure
A version is a procedure used to change the
position of the fetal presentation by abdominal
manipulation.
External Version Procedure
• Criteria
– Fetus is not engaged
– A reactive NST
– 36+ weeks gestation
• Contraindications
– A complicated pregnancy
– Multiple pregnancy
– Non-reassuring FHR
• Nursing Care
– Administer terbutaline prior to start
– Monitor maternal and fetal vital sign
– Post – assess for contractions and kick-counts
Episiotomy
Episiotomy
• Factors that predispose:
–
–
–
–
Primigravida
Large baby, macrosomia
Posterior position of baby
Use of forceps or vacuum extractor
• Preventive Measures
– Perineal massage
– Side-lying for expulsion
– Gradual expulsion
• Nursing Care
– Provide comfort and patient teaching
– After delivery- apply ice and assess site
Forceps-assisted Delivery
Used to shorten the second stage
of labor and assist the woman’s
pushing efforts.
Forceps-Assisted Delivery
• Risks
– Fetus
• Facial edema or lacerations
• Caput succedaneum or cephalohematoma
– Maternal
• Lacerations of birth canal
• Perineal bleeding, bruising, edema
• Nursing Care
– Preventive measures to decrease need for forceps
– Patient teaching
– After – assessment of newborn and assessment of
woman’s perineum.
Vacuum Extraction
Vacuum Extraction
• Used to shortening the second stage of labor
and delivery of the fetus
• Risk
– Cephalohematoma or caput succedaneum
• Nursing Care
– Keep woman and partner informed during the procedure
– After – assess newborn
CESAREAN DELIVERY
• OPERATIVE PROCEDURE IN WHICH THE FETUS
IS DELIVERED THROUGH AN INCISION IN THE
ABDOMEN
• REMEMBER -- IT IS A BIRTH !
• Mom may feel less than normal, so may need
support
• May have option of a VBAC the next time
VBAC
Vaginal Birth After Cesarean
• A woman may be considered a candidate for a
VBAC if the following guidelines are met:
–
–
–
–
With previous C-section, had low transverse incision
Has an adequate pelvis (absence of pelvic dystocia)
A woman who had a previous VBAC
Hospital must be set up to perform an emergency
cesarean within 30 minutes.
Vertical
Low Transverse
Cesarean Birth
• Nursing Care
– Frequent monitoring of woman and fetus
• Complication
– Uterine rupture
Cephalopelvic Disportion (CPD)
• Causes
– Large baby or small pelvis
– Usually diagnosed when there is an arrest in
descent
• Symptoms
– Station remains the same does not descend
• Treatment and Nursing Care
– Usually do a cesarean delivery if cause is pelvis
– Utilize other measures such as forceps, vacuum
extraction, episiotomy.
Explain
Too Slow
Too Fast
Prolonged Labor
Failure to Progress
Definition:
• A labor lasting more than 18 - 24 hours or fails to
make changes in dilation or effacement
• Cervical dilation -- Primigravida 1.2 cm / hr.
Multigravida 1.5 cm / hr
• Descent – 1 cm. / hr in primigravida and 2 cm./ hr.
in multigravida
• Etiology
– CPD - Cephalo Pevlic Disportion
– Malpresentation, malposition
– Labor dysfunction
• Therapeutic Interventions
–
1.
2.
3.
4.
depends on the cause
Provide comfort measures
Conservation of energy
Psychological support
Position changes
PRECIPITIOUS LABOR OR DELIVERY
• Labor that last less than 3 hours
• Unexpected fast delivery
• Etiology
– Lack of resistance of maternal tissue to passage of fetus
– Intense uterine contractions
– Small baby in a favorable position
• Complications/ Risks:
– If the baby delivers too fast, does not allow the cervix to
dilate and efface which leads to cervical lacerations
– Uterine rupture
– Fetal hypoxia and fetal intracranial hemorrhage
Rapid Delivery
Delivery Outside Normal Setting
• Everything is OUT OF CONTROL!
– mom is frightened, angry, feels cheated
• Nursing Care:
– Do NOT leave the mother alone
– Try to make the place clean, (don’t break down table)
– Try to get the mother in control -- Have mom pant to decrease
the urge to push
– Apply gentle pressure to the fetal head as it crowns to prevent
rapid change in pressure in the fetal head which can cause
subdural hemorrhage or dural tears.
– Deliver the baby BETWEEN contractions to control delivery
– Suction or hold baby’s head low and place on mom/s
abdomen, tie off cord
– Allow to breast feed, Document!
Premature Rupture of the Membranes
• Definition:
– Spontaneous rupture of the membranes
• Etiology
– Infections
- Incompetent cervix
– Fetal abnormalities - Sexual Intercourse
• Major risk - ascending intrauterine
infection
• Other risk -- Precipitation of labor
• Treatment and Nursing Care:
– Wait and watch, bedrest, no
intercourse
– Assess time membranes ruptures and if
labor started
– Check temperature frequently
– Describe character of amniotic fluid
– Check WBC
– Provide psychological support
Accelerating Fetal Lung Maturity
• Betamethasone (Celestone) or
dexamethasone(Decadron are given to stimulate
the lungs and accelerate fetal lung maturity
thereby decreasing chance of respiratory distress
syndrome.
• Lasts for about 7 days and need to repeat/
Preterm Labor
• Definition:
– Labor that occurs after 20 weeks but before 37
weeks
• Etiology:
– urinary tract infections
– Premature rupture of membranes
• Goal -- STOP THE LABOR ! suppress uterine
activity
Therapeutic Interventions
Drug Therapy
Tocolytics
• Uses: Stop or arrest labor
• Criteria for use, don’t give if:
– Patient is in Active labor, cervix has dilated to
4 cm. or more
– Presence of Severe Pre-eclampsia
– Fetal complications / Fetal demise
– Hemorrhage is present
– Ruptured membranes
TOCOLYTIC MEDICATIONS
β-adrenergic agonist
• Examples:
– Yutopar (ritodrine) or Brethine (terbutaline sulfate)
• SIDE EFFECTS or WARNING SIGNS:
– Palpitations
– Tachycardia - pulse ~120
– Tremors, nervousness, restlessness
– Headache, severe dizziness
– Hyperglycemia
• TOXIC EFFECTS - PULMONARY EDEMA
• rales, crackles, dyspnea noted on routine
nursing chest assessment every shift
Tocolytic Drugs
• Nursing Care:
– Stop the medication
– Start oxygen
– Give ANTIDOTE: INDERAL
Tocolytic Medications
Magnesium Sulfate
• Decreases frequency and intensity of uterine
contractions
• Given via IV infusion pump
– Loading dose 4-6 g in 100 ml given over ~20 minutes
– Maintenance dose – 1-4 g per hour.
• Side effects
– Lethargy and weakness
– Sweating, flushing,
– N/V, headache, slurred speech
• Toxic effects
– Absences of reflexes
– Respiratory depression
Tocolytic Medications
Calcium Channel Blocker
nifedipine
• Decreases smooth muscle contraction by blocking
the slow calcium channels at cell surface.
• Administration
– Orally or sublingually
• Side Effects
– Hypotension, tachycardia
– Facial flushing
– Headache
Tocolytic Medications
prostaglandin synthesis inhibitor
indomethacin (Indocin)
• Action
– Inhibits prostaglandin synthesis thus reducing uterine
contractions. (Prostaglandins stimulate uterine
contractions)
– Used for pregnancies <32 weeks gestation and not
given for more than 72 hours.
– Not a widely used medication to treat preterm labor.
Self Care Measures
•
•
•
•
•
•
Rest
Drink plenty of fluids – 2-3 quarts /day
Empty bladder every 2-3 hours when awake
Avoid lifting heavy objects
Avoid overexertion
Modify sexual activity
Preterm labor
• NURSING CARE:
– Teach how to take medication -- on time
– Teach patient to check pulse, call Dr. if > 120 –
140 (dehydration increases contractions)
– Teach to assess fetal movement daily, kick
counts
– Drink 8-10 glasses of water per day
– Monitor uterine activity -- Home monitoring -call dr. if has contractions
– Decrease activity
– Lie on side
– Keep bladder empty
Accelerating Fetal Lung
Maturity
• Betamethasone / Celestone -- provides
stressor to the lungs of the fetus to
stimulate production of surfactant
• Effective if have 24 hours prior to delivery
Prolapse of Cord
Prolapse of the Umbilical Cord
Definition:
• Prolapse of the umbilical cord thorough the
cervical canal along side of the presenting part
Etiology/ Risk Factor:
• Occurs anytime the inlet is not occluded. Fetus
is not well engaged
• GOAL:
– RELIEVE THE PRESSURE ON THE CORD
– SUPPORT MOTHER AND THE FAMILY
Prolapse of the Cord
• NURSING CARE / Therapeutic Interventions:
#1 – Get the Pressure off the Cord
place in trendelenberg or knee-chest position
OR
elevate part with sterile gloved hand
Amnioinfusion
Warmed, sterile Normal Saline or RL is introduced
into the uterus through an intrauterine pressure
catheter (IUPC)
Amnioinfusion
• Used to treat:
– Oligohydramnios
– Meconium-stained amniotic fluid
– Cord compression and variable decelerations
• Nursing Care
–
–
–
–
Assess maternal and fetal vital signs
Assess contractions
Provide comfort measures
Measure intake and output of the fluid
Nursing Care for
Prolapse of Umbilical Cord
– Palpate FHT’s, NEVER ATTEMPT TO
REPLACE CORD!
– Give O2 per mask at 10 Liters
– Cover exposed cord with sterile wet gauze
– Stay with the patient and offer support
Amniotic Fluid Embolism
• Escape of amniotic fluid into the maternal
circulation
– usually enters maternal circulation
through open sinus at placental site
• Usually fatal to the Mother
– amniotic fluid contains debris, lanugo,
vernix, meconium, etc.
Amniotic Fluid Embolism
• Signs and Symptoms:
– dyspnea
– chest pain
– cyanosis
– shock
• Therapeutic Interventions:
– Deliver the baby
– Provide cardiovascular and respiratory
support to Mom
Ruptured Uterus
• Spontaneous or traumatic rupture of the uterus
• Etiology:
–
–
–
–
Rupture of a previous C-birth scar
Prolonged labor
Injudicious use of Pitocin -- overstimulation
Excessive manual pressure applied to the fundus during
delivery
• Signs and Symptoms:
–
–
–
–
Sudden sharp abdominal pain, abdominal tenderness
Cessation of contractions
Absence of fetal heart tones
Shock
• Therapeutic Interventions:
– Deliver the baby ! / Cesarean Delivery
The stimulation of uterine contractions
before the spontaneous onset of labor, for
the purpose of accomplishing birth
Labor Readiness
• Fetal Maturity
• Cervical Readiness with utilization of the
PreLabor Status Evaluation Scoring System/
Bishop’s score
– Assesses cervical dilatation, effacement, consistency,
position, and fetal station.
– A score of 8-9 is favorable for induction
Cervix
Score
Score
Score
Score
0
1
2
3
Posterior
Midposition
Anterior
---
Consistency
Firm
Medium
Soft
---
Effacement (%)
0-30
40-50
60-70
>80
closed
1-2
3-4
>5
Position
Dilation (cm)
Methods of Inducing Labor
• Stripping the Membranes
– With a gloved finger, the amniotic membranes lying
against the lower uterine segment are separated. This
causes release of prostaglandins that stimulate uterine
contractions
• Pitocin Infusion
– The goal is to have contractions occurring every 2
minutes of good intensity with relaxation between.
– Used for induction and augmentation.
Other Methods of Induction
– Ambulation
– Nipple Stimulation --release of endogenous
Pitocin
– Enema--warmth of enema may stimulate
contractions
– Herbs
– Insertion of balloon catheter
Foley catheter with internal stylet is inserting into the os
of the cervix and the balloon is inflated with
sterile saline (~30 ml.)
Mechanical stimulation induces labor
The End
Polyhydramnios and oligohydramnios
• Polyhydramnios – excessive amniotic fluid usually
> 2000 ml.
– Associated with fetal GI anomalies and maternal diabetes
– Treatment – watch and do nothing unless becomes short
of breath and in pain – then do an amniocentesis
• Oligohydramnios – scanty amniotic fluid usually
<500 ml.
– Etiology unknown
– Risks – fetal adhesions and fetal malformations
– Treatment - amnioinfusion