Maternal-Neonatal Nursing
complications of labor & birth
16th & 17th Lectures
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Dystocia
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Dystocia is “Difficult Labor” prolonged or
abnormal labor/FAILURE TO PROGRESS IN
LABOUR
It primarily results from one of four problems
 Powers-abnormal uterine activity, ineffective
contractions
 Passageway- abnormal pelvic shape
 Passenger-abnormal fetal size or presentation
 Psyche-inadequate support, maternal stress &
anxiety
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CEPHALOPELVIC
DISPROPORTION (CPD)
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A contracted or narrow diameter in birth
passage especially if fetus is larger than
the maternal pelvic diameters.
Implications: Maternal: prolonged labor,
arrest of descent, uterine rupture, forcepsassisted birth with trauma
Implications: Fetal: cord prolapse,
excessive molding of head, birth trauma to
skull and CNS
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Nursing diagnoses r/t
dysfunctional labor
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Anxiety r/t slow progress
of labor
Fatigue r/t the length of
labor
Ineffective individual
coping r/t inability to
relax
Fluid volume deficit r/t
lack of fluid intake
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Risk for Infection r/t
prolonged labor
Sleep pattern
disturbance r/t
maternal exhaustion
and inability to relax
Knowledge deficit r/t
potential fetal
distress and fetal
sepsis
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Management of Labor Dystocia
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Augmentation of labor-use of drugs to enhance
labor that has already begun
 Amniotomy
 Oxytocin Augmentation
Assisted and Operative Delivery
 Vacuum - Assisted Delivery
 Forceps Delivery
 Cesarean Birth
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Oxytocin induction &
augmentation
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Prior to administration of oxytocin a full
assessment is preformed to determine cervical
status, FHR, fetal presentation and station. The
woman is placed on continous EFM
Oxytocin is administer IV through a controlled
infusion pump and diluted in an intravenous
solution
Vital signs are recorded frequently
Urinary out put is recorded as urine out put can
decrease and water can be retained (maternal
water intoxication)
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Side effects of oxytocin
administration
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Water intoxication- headache, nausea &
vomiting, decreased urinary output,
hypertension, tachycardia and cardiac
arrhythmias
Hyperstimulation of the uterus
Uterine rupture
A rapid labor with potential uterine or
cervical lacerations
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Nursing interventions when
administering oxytocin
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Observe for signs of water intoxication
Changes in FHR-non reassuring FHR
Contractions lasting longer than 90 seconds
with frequency of 1 minute
Assess cervical dilation and progression of
labor
If non reassuring FHR occurs or
hyperstimulation of the uterus occurs the
infusion is stopped immediately and MD
informed
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Contraindications for the
induction of labor
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Previous classic uterine incision
Cephalopelvic disproportion
Placentia previa
Active genital herpes
Preterm fetus
Fetal malposition-breech
Multiple gestations
Nonreassuring fetal status
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Case 1
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You are working at the ED. A G9P2 patient presents
to the department. Her water broke 1 hour ago, she
is having frequent contractions and she feels the
head coming out.
A delivery tray is available and the patient is in
lithotomy position. She is pushing with each
contraction and the baby’s head starts to come out.
However, with each push, the baby’s head comes
out and then retracts back in towards the perineum.
You quickly recognize this as the sign of shoulder
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dystocia.
Shoulder Dystocia
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be defined by a prolonged head-to-body delivery
time (> 60 s) due to impaction of the fetal
shoulders within the maternal pelvis
Risk factors: macrosomia, post-term, maternal
obesity
Maternal morbidity: 4th degree perineal, cervical &
vaginal lacerations, bladder injury, postpartum
hemorrhage, endometritis
Fetal morbidity: brachial plexus injury, clavicular
fracture, facial nerve paralysis, asphyxia, CNS
injury, death
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ERB or brachial plexus
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Shoulder DystociaManagement
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Obstetrical Maneuvers
 Rotation and Delivery
of Posterior Shoulder
 Maternal Position
Change
 Issue of Fundal
Pressure
 Episiotomy
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Case 2
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You are working in a small ED and a
35 week G4P3 presents with ROM and
contractions. She is quite distressed
and thinks the baby is coming out.
You perform a pelvic examination and
next to the head you feel a pulsate
cord…
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Prolapse of the umbilical cord
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When the umbilical cord precedes the fetal presenting part
it is said to be prolapsed, this can interfere with fetal
circulation
Factors that contribute to prolapsed cord are
Rupture of membranes before head is engaged
Small fetus
Breech presentations and transverse lie
Hydramnios
Unusually long cord
Multifetal pregnancy
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Nursing actions to relieve
prolapsed cord
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Place woman’s hips higher than her head- kneechest position, trendelenburg’s position, or side
lying with hips elevated on a pillow
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With a sterile glove push fetal presenting part away
from cord
Give oxygen at 8 to 10 L/Min
Monitor FHR
Prepare for rapid vaginal or caesarian birth
If cord protrudes apply sterile saline soaked towels to
prevent drying of the cord and maintain blood flow
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FETAL DISTRESS
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Common causes: cord compression,
uteroplacental insufficiency, placental
abnormalities, meconium-stained amniotic fluid
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Correct maternal hypotension and enhance
uteroplacental blood flow
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Change position that improves FHR,
Increase rate of IV
O2 via face mask
Decrease uterine activity: adm tocolytic
Perform vaginal exam (prolapsed
cord?)
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Indications for operative
vaginal delivery
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Fetal Distress An irregular fetal heart beat
 Bradycardia, under 100 beats per minute,
between uterine contractions
 A rapid fetal heart - more than 160 beats per
minute
 The passage of Meconium in cephalic
presentations
Maternal Conditions
 Maternal distress or exhaustion: This is shown by
dehydration, pulse above 100 and temperature.
 Maternal disease: When the mother has cardiac
disease, toxemia, forceps & vacuum can be used
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to shorten the second stage.
Assisted and Operative
Delivery- Vacuum
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Mechanism: Suction and Traction used to assist delivery
of presenting part.
 Indication: Most commonly related to prolonged 2nd
Stage of Labor.
 Contraindications: Cephalopelvic Disproportion (CPD);
Most malpresentations and malpositions; extreme
prematurity.
Nursing Responsibility: FHR checks q 5 minutes;
Hand held suction pump. Pressure release between
UC’s; Assess neonatal head for Cephalohematoma
after delivery.
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Assisted and Operative
Delivery- Forceps Delivery
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Mechanism: Traction and rotation of fetal presenting
part with curved metal tongs.
Indication: Prolonged 2nd stage (> 3 hrs); maternal
exhaustion;
Contraindications: Cephalopelvic Disproportion (CPD);
Most malpresentations and malpositions.
Disadvantages: Maternal and fetal trauma
(Caphalohematoma;Transient facial paralysis)
Nursing Responsibility: FHR checks q 5 minutes; obtain
forceps; assess neonate and mother for trauma.
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Cesarean Birth Definition
a surgical incision made into the abdomen and uterus
to deliver the fetus after 32 WK gestational age. It
is called hysterotomy, if removal is done before 32
weeks of pregnancy
Types of Cesarean (Uterine) Incisions
-Lower Uterine Segment (Low Transverse)
-Classical (Vertical Midline)
Only L. Uterine Segment Cesareans allow a trial of labor with
the next pregnancy.
Classical is used for emergency Cesareans or for some mal
presentations.
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Uterine Incisions
Kerr Incision vs Sellheim Incision vs Classical
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Skin Incision
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Transverse (Pfannenstiel)-lower
uterine segment
Adv: below pubic hair line, less bleeding,
better healing,cosmatic
 Disadv: difficult to extend if needed, requires
more time, if adipose fold difficult to keep
clean and dry
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Vertical-between naval and symphysis
Adv: quicker, more room
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 Disadv: scar obvious,
longer
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INDICATIONS FOR ELECTIVE
CS
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Known CPD
Fetal macrosomia
> 4500 gm
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Placenta previa
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HIV
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Active herpes
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Repeat CS
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Previous uterine surgery
eg. Hystrotomy,
myomectomy
Severe IUGR
Breech
Multiple pregnancy
Transverse lie
Ca of the Cx/ obstructing
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birth canal
INDICATIONS FOR
EMERGRENCY CS
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Severe PET,
Abruptio placntae, APH
Fetal distress
Failure to progress in the first stage of labour
Cord prolapse
Obstructed labour
Failed induction; failed vacuum or forcepes
Malpresentation  brow, face, shoulder &
compound presentations, breech
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COMPLICATIONS- Mother
INTRAOPERATIVE
 Bleeding & the need for bld transfusion
 Hysterectomy, Fetal injury
 Complications of anesthesia
 Damage to the bladder, ureter, colon , retained placental
POSTOPERATIVE
 Gaseous distension, Paralytic ileus
 Wound dehiscence & infection
 Infections  UTI, pulmonary
 DVT & pulmonary embolism, Death
 Longer hospital stay
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 Risk for maternal/infant attachment
COMPLICATIONS-the baby
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Premature birth. If the due date was not
accurately calculated, the baby could be
delivered too early.
Breathing problems. Babies born by
cesarean are more likely to develop
breathing problems such as transient
tachypnea (abnormally fast breathing during
the first few days after birth).
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Low Apgar scores. dr.Shaban
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Nursing care in the
preoperative period
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NP0
IV fluids
Insertion of urinary catheter
Medication may be given IV to prevent stomach
irritation or aspiration
Consent is obtained
Pubic shave now not needed
Patient teaching and explanations of events
Assessment of FHR, maternal vital signs
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Nursing care intraoperative period
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Skin
preparations
Draping
COUNTS
Sterile field
maintenance
Step 14: Uterus is closed in 2 layers
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Postoperative care
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Monitor vital signs every 15 minutes for first hour, then
every 30 mins in second hour then hourly until
transferred to postpartum unit
Administer oxygen as ordered
Assess fundus for firmness, height, location, massage
fundus if boggy
Assess vaginal bleeding for color amount and
consistency
Assess abdominal dressing for bleeding
Assess urine output
Change woman’s position
Allow the mother to breast feed as soon as she wishes
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Postoperative care-Cont.
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Women should be offered Pethidine (100mg im). Avoid over
sedation as this will limit mobility
If the woman is receiving IV fluids, they should be continued until
she is taking liquids well. A liquid diet if bowel sounds are heard
Removal of the urinary bladder catheter should be carried out
once a woman is mobile
Ambulation enhances circulation, encourages deep breathing and
stimulates return of normal gastrointestinal function. Encourage
foot and leg exercises and mobilize as soon as possible, usually
within 24 hours
If the dressing comes loose, reinforce with more tape rather than
removing the dressing. This will help maintain the sterility of the
dressing and reduce the risk of wound infection .1st dressing
changed by doctors .
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