Childbirth At Risk
Labor Related Complications
Chapter 21
Heather Bailey, RN, BSN
Psychologic Disorders

Characterized by alterations is thinking,
mood or behavior
 Depression, bipolar disorder, anxiety,
phobias, obsessive-compulsive disorder,
posttraumatic stress disorder, schizophrenia
and mental retardation
Nursing Care

Decrease anxiety
 Assist with coping
 Keep oriented to reality
 Promote optimal functioning
 Increased need for teaching
Dysfunctional Labor

Dystocia
 Hypertonic Labor
 Hypotonic Labor
 Precipitous Labor
Hypertonic Labor

Ineffective contraction of poor quality,
increased resting tone
 Contractions are painful but ineffective to
progress labor
 Attempt to make the labor more functional
 Keep the woman as comfortable as possible,
help her to cope
Hypotonic Labor

Less than 2-3 contractions in a 10 minute
period
 Happens with an overstretched uterus,
bowel or bladder distention and CPD
 Active management of labor
 Help the woman cope with a long labor
Precipitous Labor

Labor that lasts less than 3 hours and results in
rapid birth
 Multiparity, large pelvis, previous precipitous
labor and/or small fetus in favorable position
(preterm)
 Assist the woman to cope, be prepared for birth at
any time
 Discontinue oxytocin with accelerated labor
pattern
Postterm Pregnancy

Greater than 42 weeks complete weeks
gestation
 Not common but there are many risks
associated with postterm pregnancy
Risks of Postterm Pregnancy

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Labor induction
Large-for-gestational age
infant or Intrauterine
Growth Restriction
Operative vaginal delivery
Cesarean birth
Increased psychological
stress
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Decreased placental
perfusion
Oligohydramnios
Meconium aspiration
Fetal trauma
Non reassuring fetal
status
Postterm Care

Closely monitor FHR for non reassuring
fetal status
 Monitor after rupture of membranes for
meconium
 Prepare for infant resuscitation after birth
Fetal Malposition

Occiput posterior position
 Persistent occiput posterior position
 Monitor labor for progress
 Change position frequently, hand/knees is
helpful to help rotate the fetus to occiput
anterior position
 Prepare for forceps to be used to rotate the
fetal head
Fetal Malpresentation

Brow
 Face
 Breech
 Transverse lie
Brow Presentation

Forehead of the fetus is the presenting part
 Occurs more often in multipara
 Possible due to lax abdominal and pelvic
muscles
 Least common type of malpresentation
Risks/Nursing Care

Maternal: prolonged labor, cesarean birth,
 Fetal: cerebral and neck compression,
damage to the trachea and larynx, facial
edema, bruising
 Frequent position changes
Face Presentation

Face of the fetus is the presenting part
 Occurs most frequently in multiparas,
preterm birth and presence of anencephaly
Risks/Care of Face
Presentation

Maternal:
– Increased risk of CPD
– Prolonged labor
– Cesarean birth

Fetal:
– Cephalohematoma of the face
– Edema of face and throat
– Pronounced molding of the head

Care is the same as for brown presentation
Breech Presentation

Frequently associated with preterm birth,
placenta previa, hydramnios, multiple
gestation, uterine anomalies and fetal
anomalies
 Types:
– Frank
– Incomplete (footling)
– Complete
Risks/Care

Prolapsed umbilical cord, ability to deliver
head but not body
 External Cephalic Version
 Cesarean Section
 May attempt delivery if proven pelvis or
multiple gestation
Transverse Lie

Associated with grand multiparity, preterm
fetus, abnormal uterus, hydramnios,
placenta previa, and contracted pelvis
 Risks: prolapsed cord
 Management: external cephalic version,
cesarean section
Macrosomic Fetus

Greater than 4000g (8# 8oz) at birth
 Most common in male infants, offspring of
large parents, diabetic women, mothers with
a previous macrosomic infant, multiparity
and prolonged gestation
Risks of Macrosomia

Maternal
– CPD
– Dysfunctional labor
– Soft tissue
laceration during
vaginal birth
– Postpartal
hemorrhage

Fetal
– Meconium
aspiration
– Asphyxia
– Shoulder dystocia
– Upper brachial
plexus injury
– Fractured clavicles
Multiple Gestation

Associated with infertility treatments
 Spontaneous twins are more common in
African Americans, advanced maternal age,
women who are tall and overweight
Maternal Implications

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Urinary tract infections
Preeclampsia
Preterm labor
Placenta previa
Abnormal presentation
Uterine dysfunction
Prolapsed cord
Intrapartum/Postpartum hemorrhage
Fetal/Neonatal Implications

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Higher perinatal mortality rate
Intrauterine growth restriction in one or both
babies
Increased incidence of fetal anomalies
Prematurity and associated risks
Abnormal presentation
Cerebral palsy
Long term disabilities
Twin to twin transfusion
Care of Multiple Gestation

Bed rest/Pelvic rest
 Weekly-Biweekly NST/BPP after 30-34
weeks
 Large bore IV, type and crossmatch
 Prep for both vaginal and cesarean delivery
if vaginal birth is attempted
 Duplication of everything in the delivery
room
Non Reassuring Fetal Status

Usually caused by cord compression or
uteroplacental insufficiency
 If hypoxia persists permanent damage to the
fetus may occur
 Most common signs are meconium stained
amniotic fluid and non reassuring fetal heart
tones
Intrauterine Resuscitation

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Left lateral position
IV fluid bolus
Right side or knee/chest if left lateral does not
work
Discontinue the oxytocin if applicable
Oxygen at 8-10 L/min via facemask
Vaginal examination
Possible tocolytic
Prepare for emergency delivery
Placental Problems

Abruptio placentae
 Placenta previa
 Placenta accreta
 Vasa previa
 Retained placenta
Placenta Previa

Placenta is implanted in the lower uterine segment
 Bleeding begins as the uterus contracts and the
cervix dilates
 Types
– Complete
– Partial
– Marginal
– Low lying
Risk Factors

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Minority women
Previous cesarean section
Multiparity
Advanced maternal age
Previous miscarriage
Previous induced abortion
Cigarette smoking
Male fetus
Expectant Management

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Bed rest with bathroom privileges (if not actively
bleeding)
No vaginal exams
Monitoring blood loss, pain and contractions
FHR evaluation
H&H, Rh factor, type and crossmatch
Intravenous fluid with Lactated Ringers
Cesarean birth for profuse or recurrent bleeding
Nursing Measures

Contraction and fetal heart rate evaluation
 Intake and output
 IV fluid
 Maternal vital signs
 Chux weight for monitoring of blood loss
Abruptio Placentae

Premature separation of the placenta from
the uterus
 Leading cause of perinatal mortality
 Types:
–
–
–
–
Marginal
Central
Complete
Grades 1, 2 and 3
Risk Factors

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Increased maternal age
Increased parity
Cigarette smoking
Cocaine abuse
Trauma
Maternal hypertension
Previous abruption

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Rapid uterine
decompression
PPROM
Uterine malformations
Fibroids
Placental anomalies
Inherited
thrombophilia
Maternal Risks

Hemorrhage
 Hemorrhagic shock
 DIC
 Renal failure
 Death
Fetal Risks

Preterm problems
 Anemia
 Hypoxia
 Brain damage
 Death
 Best survival rate if delivered within 20
minutes of initial separation
Care of Placenta Abruption

Large bore IV
 Type and Crossmatch
 If separation is severe immediate delivery is
indicated
 If separation is mild pregnancy can be
maintained with bed rest if preterm or a
vaginal delivery may be attempted if near
term
Placenta Accreta

When the placenta grows through the uterus
usually through a previous cesarean scar
 Placenta previa is also associated with this
 Complication is hemorrhage resulting from
being unable to remove the placenta
 Hysterectomy may be necessary
Retained Placenta

Occurs when the placenta does not separate
from the uterus within 30 minutes after
delivery
 Manual removal is required by the
physician
 Surgical curettage may be required if unable
to remove manually
 Can result in postpartum hemorrhage
Lacerations

Cervical
 Periurethreal
 Vaginal
– First degree
– Second degree
– Third degree
– Fourth degree
Prolapsed Umbilical Cord

When the cord precedes the fetal presenting
part it becomes trapped between the
presenting part and the cervix
 Compression results in blood flow being
restricted to the infant
Care of Prolapsed Cord

If a cord is discovered upon vaginal exam
the hand must remain in the vagina to
relieve pressure on the cord
 Knee/chest position or Trendeleberg may
also help
 This is what will save the life of the baby
 Patient will be prepared for immediate
delivery via cesarean section
Amniotic Fluid Embolism

Occurs with a tear in the amnion or chorion
in the uterus allowing amniotic fluid to
enter the vascular system
 Can also enter via placental abruption,
ruptured uterus or cervical tears
 The fluid enters the lung and lodges there
after traveling through the vascular system
Signs/Symptoms

Sudden onset of respiratory distress
 Dyspnea
 Cyanosis
 Hemorrhagic shock
 Coma
 Death
Hydramnios

More than 2000 mL of amniotic fluid
 Associated with major congenital anomalies
–
–
–
–

Malformations affecting the swallowing mechanism
Neurological disorders where the meninges are exposed
Anencephaly
Monozygotic twins due to the twin with increased
blood volume with excessive urination
Maternal disorders
– Rh sensitization
– Multiple gestation pregnancy
Risks of Hydramnios

Maternal

Fetal
– Shortness of breath
– Increased mortality
– Lower extremity
rate due to increased
incidence of
malformations
– Prolapsed cord
– Malpresentation
edema
– Placental abruption
– Dysfunctional labor
– Postpartum
hemorrhage
Oligohydramios

Amount of amniotic fluid is severely
reduced
 Associated with:
– Postmaturity
– IUGR
– Placental insufficiency
– Fetal renal malformations
Oligohydramnios Risks

Dysfunctional labor
 Fetal adhesions if early in pregnancy
 Pulmonary hypoplasia
 Cord compression
 Meconium stained fluid
Cephalopelvic Disproportion

CPD
 Associated with pelvic contractures, fetal
malpresentation and fetal macrosomia
 Labor is prolonged and cesarean section is
indicated
 Should be suspected when adequate labor
does not result in labor progress
Perinatal Loss

Death of fetus or infant from the time of
conception through 28 days of life
 Many causes or the cause may be unknown
Maternal Factors

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Postterm pregnancy
Diabetes
Chronic hypertension
Preeclampsia/
eclampsia
Advanced maternal
age

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Thrombophilias
Antiphospholipid
syndrome
Uterine rupture
Rh disease
Infection
Fetal Factors
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Chromosomal disorders
Birth defects
Anencephaly
Open neural tube defects
Congenital heart defects
Hydrops fetalis
Infection
Complications of multiple gestation
Other Factors

Placenta previa
 Placental abruption
 Cord accident
 Premature rupture of membranes
 Unknown factors
Complications

Prolonged retention of the dead fetus can
result in DIC
 Infection can result with prolonged
retention resulting in endometritis or sepsis
 In the case of twins delivery may need to be
delayed if one is living and one is not
Diagnosis/Treatment

No fetal movement later in pregnancy
 Absence of fetal heart tones with Doppler
 Confirmed by ultrasound and absence of
heart motion and/or Spalding’s sign
 Delivery is the only treatment and must be
precipitated to decrease complications
 Delivery depends on gestation and previous
deliveries
Evaluation

Before birth: type and Rh, CBC,
coagulation studies
 After birth: careful of inspection of fetus,
placenta and umbilical cord
 Placenta to pathology for testing
 Autopsy if parents consent
Preparation for Birth

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Let the family know what to expect based on
gestation and time the fetus has been dead
Assist through the grief process
Comfort and care for the patient and the family
Keep the patient as comfortable as possible
If term, follow the birth plan set forth by the
patient, preterm follow as much as possible
After Delivery

Prepare the infant for viewing by the family
as much as possible
 Prepare the family for what to expect
– What the infant looks like
– He/she will be cold
– Color of the infant
– Any birth defects
After Delivery

Allow the family to hold the infant as long
as they want
 Collect locks of hair, foot prints, hand
prints, crib cards, identification bands,
pictures, birth certificate in a remembrance
box for the parents
 If they decline the box, keep it for them,
they may want it later
Discharge Care

Teach the patient what to expect mentally and
physically
 They will have some of the same postpartum
issues as someone that delivered a live baby like
milk coming in
 Refer family to support groups, counselors and
provide written material for them to refer to
 Remind them that things like mother’s day,
father’s day and birthday will be difficult in the
future