Notes
Complications of Labor and Delivery
The successful completion of the 40 week gestational period requires the harmonious
functioning of four components: Psyche, Powers, Passenger, Passageway.
A disruption in any of these components may cause DYSTOCIA. Dystocia is an
abnormal, long, or difficult labor or delivery.
Complications of the Psyche
Hormones released in response to anxiety or stress can cause DYSTOCIA. Sources of
stress vary for each individual, but pain and the absence of a support person are the two most
common factors.
Intense anxiety stimulates the Sympathetic nervous system which in turn releases
catecholamines which lead to myometrial dysfunction. Norepinephrine and epinephrine lead to
uncoordinated or increased uterine activity.
Nursing Care:
1. Assess support available and be there for the patient
2. Patient Teaching on breathing and relaxation measures
3. Non-Pharmacological and Pharmacological Measures
4. Keep informed of progress
5. Provide quiet calm environment
Complications of the Powers
Uterine Dysfunction
Uterine dystocia’s occur when labor contractions (powers) are ineffectual, erratic or unable
to do the work of dilation and effacement of the cervix.
I.
HYPERTONIC UTERINE CONTRACTIONS
Most often occur in first-time mothers, primigravidas. The contractions are uncoordinated,
involve only a portion of the uterus, and are ineffective B they do not bring about dilation
and effacement. The contractions increase in frequency, but the intensity is decreased.
Signs and Symptoms:
1. PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain.
2. Dilation and effacement the cervix does not occur.
3. Prolonged latent phase. Stay at 2 - 3 cm. - don’t dilate as should.
4. Fetal distress occurs early – uterine resting tone is high; decreasing placental
perfusion.
5. Anxious and discouraged
Goal: Relieve pain and promote normal labor pattern
Treatment of Hypertonic Uterine Contractions:
1. Provide with COMFORT MEASURES and Therapeutic Rest
Warm shower
Mouth Care
Imagery
Music
Back rub
2. Mild Sedation or some analgesics
3. Bedrest - allow to sleep and when awakens uterine contractions may be normal
4. Hydration
5. Tocolytics to reduce high uterine tone
II. HYPOTONIC UTERINE CONTRACTIONS B UTERINE INERTIA
Most often occurs in the multigravida patient. Labor starts out normal and progresses
through the latent phase. Once the patient reaches the active phase there is marked slowing
of contractions (2 - 3 contractions in 10 minutes). The uterus is indentable even at acme of
contraction.
Etiology and Pathophysiology:
1. Overstretching of the uterus - large baby, multiple babies, polyhydramnios,
multiple parity
2. Bowel or bladder distention preventing descent
3. Excessive use of analgesia / anesthesia
Assessment:
Signs and Symptoms of HYPOTONIC UTERINE INERTIA:
1. Weak contractions, infrequent and brief, and can be easily indented with fingertip
pressure at peak
2. Prolonged ACTIVE Phase
3. Exhaustion of the mother
4. Psychological trauma - frustrated
Intervention:
Treatment of Hypotonic Uterine Inertia:
1. Ambulation
2. Nipple Stimulation - release of endogenous Pitocin
3. Enema - warmth of enema may stimulate contractions
4. Amniotomy - artificial rupture of the membranes
5. Augmentation of labor with the use of Pitocin
AMNIOTOMY
I.
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
II. Disadvantages of an Amniotomy
Delivery must occur
Increase danger of prolapse of umbilical cord
III. Nursing Care:
#1-Check the fetal heart tones
Assess color, odor, amount
Provide with perineal care
Monitor contractions
Check temperature every 2 hours
PITOCIN
I.
Induction of Labor – Bishop’s Score
II.
Augmentation of Labor
Use only if CPD (cephal pelvic disportion) is not present
Give 20 units/1000 cc. fluid or 30 units/500 cc fluid. Hang as a secondary infusion,
never as primary
GOAL: Achieve contractions every 2 - 3 minutes of good intensity with relaxation
between
Nursing Care:
1. Assess contractions - are they increasing but not tetanic
2. Assess dilation and effacement
3. Monitor vital signs and FHT’s
III. PROLONGED LABOR
A labor lasting more than 18 - 24 hours
Cervical dilations (Primigravida 1.2 cm/hr Multigravida 1.5 cm/hr)
Descent of fetus should be 1 cm/hr. primigravida; 2 cm/hr in multigravida
Etiology:
CPD - Cephalo Pelvic Disportion
Malpresentation, malposition
Labor dysfunction
Therapeutic Interventions:
Depends on the cause:
1. Comfort measures
2. Conservation of energy
3. Psychological support
4. Position changes
5. Pitocin augmentation
IV. PRECIPITOUS LABOR OR DELIVERY
A precipitous labor is one that lasts less than 3 hours. A precipitous delivery is an
unexpected fast delivery B many times outside of a sterile environment.
Etiology:
Lack of resistance of maternal tissue to passage of fetus
Intense uterine contractions
Small baby in a favorable position
Complication:
1. If the baby delivers too fast, does not allow the cervix to dilate and efface which
leads to cervical lacerations
2. Uterine rupture
3. Fetal hypoxia and fetal intracranial hemorrhage
Nursing Care in a Rapid Delivery - Delivery Outside Normal Setting
Everything is OUT OF CONTROL! The patient is frightened, angry, feels cheated
1.
2.
3.
4.
5.
6.
7.
8.
Do NOT leave the mother alone - stay with her and provide reassurance.
Try to make the place clean, (don’t break down table) place something clean under her
hips.
Try to get the mother in control - Have mom pant or blow out 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, tie off the cord, and place on mom’s abdomen.
Massage the uterus. Allow to breast feed.
Document!
Complications of the Passageway
Pelvic Dystocia
Pelvic Inlet or Outlet is not of sufficient size or proper shape to allow the baby to get
through.
Etiology:
Congenital defect; Malnutrition (Rickets); Neoplasms; Fracture/Trauma.
Assessment:
Signs and Symptoms:
Labor is arrested. Station does not decrease. It remains the same.
Therapeutic Interventions:
Cesarean delivery
Complications of the Passenger
Malpositions:
Posterior position - usually mom complains of back pain
Treatment:
1. Forceps - low forceps or outlet forceps usually applied after crowning
2. Vacuum extraction - disk shaped cup placed over vertex of head and vacuum applied
3. Episiotomy - surgical incision to allow more room
Malpresentation:
brow, face, transverse, breech
Treatment:
1. May allow to deliver vaginally with caution or C-birth
2. Version B alteration or turning of the fetus to alter the position by abdominal or
intrauterine manipulation
External version - attempt to turn the fetus from a breech to a vertex presentation
Internal version - physician inserts a hand into the uterus and changes the
presentation to cephalic. Used to deliver the second fetus in
the case of twins.
Cephalopelvic Disproportion:
Large baby or small pelvis. It is usually diagnosed when there is an arrest in descent.
Station remains the same.
Therapeutic Interventions:
Cesarean Delivery
Multiple Fetuses:
May be delivered by cesarean birth
CESAREAN DELIVERY
An 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 (Vaginal Birth After Cesarean) the next time
Premature Rupture of the Membranes
Definition:
Spontaneous rupture of the membranes before labor begins.
Etiology and Pathophysiology:
1. Infections
2. Fetal abnormalities
3. Incompetent cervix
4. Recent sexual intercourse
Major risk:
1. Ascending intrauterine infection
2. Precipitation of labor
Therapeutic Interventions:
Treatment and Nursing Care:
1. Wait and watch, bedrest, no intercourse, shower only, no tub baths
2. Betamethasone / Celestone B provides stressor to the lungs of the fetus to stimulate
production of surfactant
3. Assess time membranes ruptures and if labor started
4. Check temperature frequently. Every 4 hours while awake. Report an increase of
100.4
5. Describe character of amniotic fluid and report foul smelling or increase in amount
6. Check WBC
7. Provide psychological support
Preterm Labor
Definition:
Labor that occurs after 20 weeks but before 37 weeks.
Etiology:
Most common causes: urinary tract infections and premature rupture of membranes.
Therapeutic Interventions:
Goal : STOP THE LABOR! Suppression of uterine activity
a.
Drug Therapy – Tocolytics (beta-adrenergic)
Uses: stop/arrest labor.
Criteria for use – Do not give if:
1. Patient is in active labor, cervix has dilated to 4 cm. or more
2. Presence of severe pre-eclampsia
3. Fetal complication / fetal demise
4. Hemorrhage is present
5. Membranes have ruptured\
Side effects:
1. Palpitations
2. Tachycardia
3. Tremors, nervousness
4. Headache
5. Hyperglycemia
Toxic effects:
1. PULMONARY EDEMA – noted upon routine chest assessments of rales and
dyspnea.
2. Antidote: Inderal (beta-blocker)
b.
NURSING CARE:
1. Teach how to take medication on time
2. Teach patient to check pulse, call Dr. if > 120 - 140
3. Teach to assess fetal movement daily, kick counts
4. Drink 8 - 10 glasses of water/day
5. Monitor uterine activity.
6. Decrease activity; lie on side
7. Keep bladder empty.
8. Pelvic rest.
Ruptured Uterus
Definition:
Spontaneous or traumatic rupture of the uterus
Etiology:
1. Rupture of a previous C-birth scar
2. Prolonged labor
3. Injudicious use of Pitocin
4. 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
Prolapse of the Umbilical Cord
Definition:
Prolapse of the umbilical cord through the cervical canal along side of the presenting part.
Etiology:
Occurs anytime the inlet is not occluded. Fetus is not well engaged. Occurs with rupture of
membranes.
Goal:
Relieve the pressure on the cord to maintain oxygenation of the fetus
Support the mother and the family
Therapeutic Interventions:
1. Get the pressure off the Cord - place in trendlenberg or knee-chest position OR elevate
part with sterile glove. Must have pulsating cord.
2. Palpate FHT’s, NEVER ATTEMPT TO REPLACE CORD!
3. Give O2 per mask - 10 - 12 liters
4. Cover exposed cord with sterile wet gauze
5. Stay with the patient and offer support
Amniotic Fluid Embolism
Definition:
Escape of amniotic fluid into the maternal circulation. It usually enters maternal circulation
through open sinus at placental site. Usually fatal to the mother because amniotic fluid contains
debris, lanugo, verni, meconium, etc.
Signs and Symptoms:
dyspnea
chest pain
cyanosis
shock
Therapeutic Interventions:
Deliver the baby
Provide cardiovascular and respiratory support to Mom
ICU