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