Ch. 16- Complications Related to the Labor Process
● Prolapsed Umbilical Cord - occurs when umbilical cord is displaced, preceding presenting part of fetus
or protruding through cervix. The result is cord compression and compromised fetal circulation
o stick hand in and get pressure off cord
o Assessment
▪ Risk factors
● rupture of amniotic membrane
● abnormal fetal presentation (any presentation other than vertex [occiput as
presenting part])
● transverse lie: presenting part not engaged, which leaves room for cord to descend
● small-for-gestational-age fetus
● unusually long umbilical cord
● multifetal pregnancy
● unengaged presenting part
● hydramnios or polyhydramanios
▪ expected findings - pt report that feels something coming through her vagina
▪ Physical assessment findings
● visualization/palpation of umbilical cord protruding from introitus
● FHR monitoring shows variable/prolonged deceleration
● excessive fetal activity followed by cessation of movement; suggestive of severe
fetal hypoxia
o nursing care
▪ use sterile-gloved hand, insert 2 fingers into vagina, and apply finger pressure on either
side of the cord to fetal presenting part to elevate it off cord.
▪ apply warm, sterile, saline-soaked towel to the visible cord to prevent drying and
maintain blood flow
▪ reposition pt to knee-chest, Trendelenburg, or side-lying position w/ rolled towel under pt
right/left hip to relieve pressure on cord
▪ provide continuous electronic monitoring FHR for variable deceleration, which indicate
fetal asphyxia/hypoxia
▪ admin O2 8-10L face mask to improve fetal O2
▪ initiate IV and admin fluid bolus
▪ prepared for immediate vaginal birth if cervix fully dilated or C-section it not
● Meconium-stained amniotic fluid - meconium passage in amniotic fluid during antepartum period
prior to start of labor is typically not associated w/ unfavorable fetal outcome. Fetus had episode of loss
of sphincter control, allowing meconium to pass into amniotic fluid
o risk for aspiration
o older they are more likely
o amniotic fluid greenish
o Assessment
▪ risk factors
● increased incidence for meconium in amniotic fluid after 38wks of gestation d/t
fetal maturity of normal physio functions
● umbilical cord compression results in fetal hypoxia that stimulates vagal nerve in
mature fetuses
● hypoxia stimulates vagal nerve, which induces peristalsis of fetal GI tract and
relaxation of anal sphincter
▪ Expected Finding
● amniotic fluid can vary in color = black to greenish, yellow, brown. through
meconium-stained amniotic fluid is often green. consistency can be thin/thick
● criteria for evaluation of meconium-stained amniotic fluid
o often present in breech presentation, and might not indicate fetal hypoxia
o present w/ no changes in FHR
o stained fluid accompanied by variable/late deceleration in FHR (ominous
sign)
▪ Diagnostic procedure - electronic fetal monitoring
▪ pt centered care - nursing care
● document color/consistency of stained amniotic fluid
● notify neonatal resuscitation team to be present at birth + gather equipment
needed for neonatal resuscitation
● follow suction protocol
o assess neonate’s resp effort, muscle tone, and FHR
o suction mouth/nose using bulb syringe in resp efforts strong, muscle tone
good, and HR >100bpm
o suction below vocal cords using endotracheal tube before spontaneous
breaths occur if resp are depressed, muscle tone decreased, and HR
<100/min
● Fetal distress - present when FHR below 110, or above 160. FHR shows decreased or no variability.
fetal hyperactivity or no fetal activity
o expected findings - nonreassuring FHR w/ decreased or no variability
o diagnostic procedures
▪ monitor uterine contractions
▪ monitor FHR
▪ monitor findings of ultrasound and other prescribed diagnostics
o risk factors
▪ fetal/uterine anomalies
▪ complications of labor and birth
o pt centered care / interventions - nursing care
▪ position pt on Left-side lying reclining position w/ legs elevated
▪ o2 -8-10L face mask
▪ turn off Oxytocin
▪ IV fluid increase to treat HypoTN
▪ monitor vitals/FHR
▪ prepare pt for emergency C-section
● Dystocia (dysfunctional labor) -difficult/abnormal labor related to 5Ps of labor. Atypical uterine
contraction patterns prevent normal process of labor and progression. contractions can be hyper/hypotonic w/ failure to efface and dilate cervix.
o dilation can’t happen
o pitocin to help, but it cannot help also
o Risk factors
▪ short stature, overweight status
▪ age >40yr
▪ uterine abnormalities
▪ pelvic soft tissue obstructions or pelvic contracture
▪ cephalopelvic disproportion - fetal head larger than maternal pelvis
▪ congenital anomalies
▪ fetal macrosomia
▪ fetal malpresentation, malposition
▪ multifetal pregnancy
▪ hypertonic/hypotonic uterus
▪ maternal fatigue/fear/dehydration
▪ inappropriate timing of anesthesia/analgesics
o expected findings
▪ lack of progress in dilation, effacement, or fetal descent during labor
● hypotonic uterus easily indentable, even at peak of contraction
● hypertonic uterus can’t be indented, even b/ contractions
▪ pt ineffective in pushing no voluntary urge to bear down
● persistent occiput posterior presentation = fetal occiput directed toward posterior
maternal pelvis rather than anterior pelvis
● persistent occiput posterior position prolongs labor and pt reports increased back
pain as fetus presses against maternal sacrum
o Diagnostic/therapeutic procedures
▪ ultrasound
▪ amniotomy = stripping of membrane if not ruptured
▪ oxytocin infusion
▪ vacuum-assisted birth
▪ C-section
o pt-centered care
▪ dysfunctional labor
● assist w/ application of fetal scalp electrode/intrauterine pressure catheter (IUPC)
● assist w/ amniotomy - artificial rupture of membrane
● encourage pt engage in regular voiding to empty bladder. Position change to aid
in fetal descent/open up pelvic outlet. Assist pt to position on hands/knees to help
fetus to rotate posterior to anterior position.
● encourage ambulation to enhance progression of labor.
● hydrotherapy/relaxation techniques to aid in progression of labor. apply
counterpressure using fist/heel of hand to sacral area to alleviate discomfort
● assist pt into beneficial position for pushing and coach about bearing down w/
contraction
● prepare for possible forceps-assisted, vacuum-assisted, or C-birth
● continue monitoring FHR in response to labor
▪ Hypertonic contractions
● maintain hydration, promote rest/relaxation and provide comfort measure b/
contractions.
● place pt in lateral position, provide O2 by mask
o Medications - admin analgesic prescribed - for rest from hypertonic contractions
▪ Oxytocin - used to augment labor and strengthen uterine contraction
▪ Oxytocin is not administered for hypertonic contractions.
● Precipitous Labor - labor that lasts 3H or less from onset of contractions to time of delivery. FAST 3hrs or less, onset of contraction to delivery of baby - don’t leave them
o don’t try to stop delivery - but try to slow down
o light pressure on baby head
o traumatic on perineum tissues
o can happen w/o medication, first delivery
o Risk factors
▪ hypertonic uterine dysfunction
● nonproductive, uncoordinated, painful, uterine contractions during labor that are
too frequent and too long in duration and don’t allow for relaxation of uterine
muscle b/ contractions = uterine tetany
● hypertonic contractions don’t contribute to progression of labor - cervical
effacement, dilation, fetal descent
● hypertonic contractions can result in uteroplacental insufficiency → fetal hypoxia
▪ oxytocin stimulation
▪
● admin to augment/induce labor by increasing intensity/duration of contractions
● Oxytocin stimulation can lead to hypertonic uterine contractions
multiparous pt - can move through stages of labor more rapidly
o expected findings
▪ during labor
● low backache
● abd pressure/cramping
● increased/blood vaginal discharge
● palpable uterine contractions
● progression of cervical dilation/effacement
● diarrhea
● fetal presentation/station/position
● status of amniotic membrane - membrane can be intact/ruptured
▪ post-birth - assess
● maternal perineal area for indications of trauma/lacerations
● neonate’s color and for indication of hypoxia/bruising
● neonate’s presenting part for signs of trauma - cephalic presentation
o pt centered care
▪ don’t leave pt unattended
● provide reassurance/emotional support to help pt remain calm
● prepare for emergency delivery of neonate
▪ encourage pt to pant with open mouth b/ contractions to control urge to push
▪ encourage pt to maintain side-lying position to optimize uteroplacental perfusion and
fetal oxygenation
▪ prepare for rupturing of membranes upon crowning if not already ruptured
▪ don’t attempt to stop delivery
▪ control rapid delivery by applying light pressure to perineal area and fetal head, gently
pressing upward towards vagina = eases rapid expulsion of fetus and prevents cerebral
damage to newborn and perineal lacerations of pt
● delivery of fetus b/ contractions making sure cord isn’t around fetal neck (nuchal
cord)
● if nuchal cord happening, attempt to gently slip it over head. If not possible,
clamp cord with 2 clamps and cut b/ the clamps
▪ suction mucus from fetal mouth/nose w/ bulb syringe when head appears
▪ next, deliver anterior shoulder located under maternal symphysis pubis; next, the
posterior shoulder; and then allow rest of fetal body to slip out
o Complications
▪ Maternal
● cervical/vaginal/perineal lacerations
● resultant tissue trauma secondary to rapid birth
● uterine rupture
● amniotic fluid embolism
● postpartum hemorrhage
▪ Fetal
● fetal hypoxia d/r hypertonic contractions or umbilical cord around fetal neck
● fetal intracranial hemorrhage d/t head trauma from rapid birth
● facial bruising