Complicated Labor Patterns
Complications of Labor &
Delivery
NUR 264
If was not supposed to be hard
work, it would not have been
called LABOR.
Anonymous
Characteristics of Tachysystole Labor
• Increase contraction frequency
– < 2 min frequency, > 90 seconds duration
• Decrease contraction intensity
• Increase uterine resting tone > 20 mm Hg
• Prolonged latent phase
• Painful due to uterine
muscle anoxia
• Ineffective in dilating and
effacing cervix
Implications of Tachysystole Labor
(cont’d)
• Maternal exhaustion, dehydration,
infection
• Reduced uteroplacental exchange
resulting in nonreassuring fetal status
• Prolonged pressure on fetal head resulting
in:
– Excessive molding
– Caput succedaneum
– Cephalhematoma
Effects of labor on the fetal head. A, Caput succedaneum formation. The
presenting portion of the scalp area is encircled by the cervix during labor,
causing swelling of the soft tissue. B, Molding of the fetal head in cephalic
presentations: (1) occiput anterior, (2) occiput posterior, (3) brow, (4) face.
Nursing Plan for Tachysystole Labor
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Stop oxytocin
Increase IV rate
Administer O2 by face mask
Position in side-lying position
Provide support and encouragement
Monitor contractions and fetal status
Notify health care provider
Assist with amniotomy
Administer pharmacologic agents as ordered –
sedation
• Monitor maternal fatigue
Hypotonic Labor
• < 2 to 3 contractions in 10 minutes
• Causes:
– Fetal macrosomia
– Multiple gestation
– Hydramnios
– Grand multiparity
– CPD
Implications of Hypotonic Labor
• Help with coping abilities
• Prolonged labor results in:
– Maternal exhaustion, dehydration
– Increased incidence of infection
• Postpartum hemorrhage due to uterine
atony
• Nonreassuring fetal status
• Fetal sepsis from pathogens ascending
from birth canal
Nursing Plan for Hypotonic Labor
• Frequent monitoring of vital signs, FHR
and contractions
• Assist with amniotomy – assess amniotic
fluid for meconium
• Administer oxytocin or nipple stimulation
• Assess bladder for distention and empty
every 2 hours
• Minimize vaginal exams to decrease risk
of infection
Nursing Plan for Hypotonic Labor
(cont’d)
• Assess for signs of infection
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Maternal fever
Chills
Foul-smelling amniotic fluid
Fetal tachycardia
• Provide emotional support
• Provide information and encourage
questions
• Prepare for surgical delivery
Abnormal Presentation/Dystocia
• Abnormal flexion of head, breech, twins
• Large fetus – macrosomia
– CPD, shoulder dystocia
• Poor quality contractions
- prolonged labor
• Extensive perineal laceration at birth (3rd
or 4th degree) or vaginal trauma
• Increased fetal morbidity and mortality
Abnormal Presentations
Breech Presentations
• Likely cesarean birth
• Increased risk of prolapsed cord
• Increased risk of cervical spinal cord
injuries due to hyperextension of fetal
head during vaginal birth
• Increased risk birth trauma (especially
head) during any type of birth
Breech Presentations
Multiple Gestation
– Frequent assessment of fetal heart tones of
each fetus
– Education of mother about signs and
symptoms of preterm labor
– Encouragement of mother to rest frequently
prior to birth
– Preparation of equipment needed to care for
each individual newborn
Multiple Gestation
Multiple Gestation
Cephalopelvic Disproportion
• Occurs when fetal head is larger than
maternal pelvic diameter
• Lack of fetal descent in presence of strong
contractions
• Labor usually prolonged
Cephalopelvic Disproportion
(cont’d)
• Increase pelvic diameter during labor by
squatting, sitting, rolling from side to side,
maintaining knee-chest position, use of a
labor ball - AVOID lithotomy!
• Vaginal birth may be possible depending
upon type of CPD
• CPD may make cesarean only available
method of birth
Fetal Macrosomia
• Newborn weighing more than 4500 g or
more
• May be postterm, IDM
• Identification of fetal macrosomia is
conducted through
– Palpation of fetus in utero
– Ultrasound of fetus
– X-ray pelvimetry
• Shoulder Dystocia
Management of Fetal Macrosomia
• Continuous fetal monitoring if labor is
allowed to progress
• Requires notification of health care
provider for early decelerations, labor
dysfunction, or nonreassuring fetal status
• McRobert’s manuever – legs to chest &
suprapubic pressure
• Cesarean birth performed if fetus is
greater than 4500 g
Shoulder Dystocia
McRobert’s Maneuver
Care of Mother
• Care of mother after birth of newborn with
macrosomia requires:
– Fundal massage to prevent maternal
hemorrhage from overstretched uterus
– Close monitoring of vital signs and vaginal
blood flow
Care of Newborn
• Care of newborn with macrosomia
requires assessment of newborn for:
– Cephalhematoma
– Erb's palsy
– Fractured clavicles
– Anoxia
– Cord prolapse
Implications of Hydramnios
• Rh sensitization
• Malformations of fetal swallowing
• Neural tube defects with exposed
meninges
• Anencephaly
• Cardiac anomalies
• Esophageal or duodenal atresia
• Provide information and emotional support
Nursing Plan for
Oligohydramnios
• Reduced AFI
• Evaluate EFM tracing for variable decels or
nonreassuring fetal status
• Reposition mother to relieve cord compression
• Notify clinician of signs of cord compression
• Evaluate newborn
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Anomalies of skin & skeleton, adhesions
Pulmonary hypoplasia
Renal agenesis, lower UTI obstructive lesions
Postmaturity
Cord Prolapse
• Umbilical cord precedes fetal presenting
part placing pressure on cord and
diminishing blood flow to fetus
• Bed rest is recommended if engagement
has not occurred and membranes have
ruptured
• Assess for nonreassuring
fetal status
Cord Prolapse
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Examiner’s fingers must remain in vagina
Have patient assume knee-chest position,
Trendelenburg position, or side-lying position with hips
elevated on pillow (head/chest up if epidural)
• Apply O2 at 8 – 10 L/min
• Vaginal birth may be attempted if completely dilated and
pelvic measurements adequate
• Cesarean section is delivery of choice
Precipitous Delivery
• Precipitous birth is one that occurs rapidly
without physician or certified nursemidwife in attendance
• Mother may fear what is going to happen
and feel that everything is out of control
• Mother needs to assume comfortable
position
Precipitous Delivery (cont’d)
• Nurse scrubs his or her hands if time
permits – applies gloves
• When infant's head crowns, mother should
pant
• Gentle pressure is applied against fetal
head to prevent it from popping out rapidly
• Perineum is supported and head is born
between contractions
Postterm Pregnancy
• Postterm pregnancy may result in an increased
possibility of
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Probable labor induction
Forceps or vacuum-assisted or cesarean birth
Decreased perfusion to the placenta
Decreased amount of amniotic fluid and possible cord
compression
– Meconium aspiration
– Macrosomia or a loss of fat and muscle mass
resulting in small-for-gestational age (SGA) newborn
TABLE 21–3
Placental and Umbilical Cord Variations
TABLE 21–3 (continued)
Placental and Umbilical Cord Variations
Manual Removal of Placenta
Amniotic Fluid Embolism
• Amniotic fluid & fetal cells enter
bloodstream
• Triggers immune response similar to
anaphylactic shock
– Results in pulmonary artery vasospasm,
pulmonary hypertension, hypoxia
– Then hemorrhage and DIC
S/S of Amniotic Fluid Embolism
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Sudden onset resp. distress - dyspnea
Cyanosis
Frothy sputum
Chest pain, cor pulmonale
Tachycardia, severe hypotension
Mental confusion
Massive hemorrhage, DIC, shock
Coma and maternal death
Fetal death if birth not immediate
Nursing Plan for Amniotic Fluid
Embolism
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Summon emergency team
Positive pressure oxygen delivery
Large bore IV
CPR as needed
Prepare for cesarean, if birth has not occurred
and neonatal resuscitation
• Prepare for CVP line insertion
• Administer blood, hypotensive drugs, steroids
• 85% maternal survivors and 50% fetal survivors
have neuro damage
Birth-related Procedures
Vacuum Extractor
• Assists birth by applying suction to fetal
head
• Should be progressive descent with first
two pulls, procedure should be limited to
prevent cephalhematoma - Risk increases
if birth not within six minutes
• Increases risk for jaundice - Due to
reabsorption of bruising at cup attachment
site
Vacuum extractor traction. A, The cup is placed on the fetal occiput and
suction is created. Traction is applied in a downward and outward
direction. B, Traction continues in a downward direction as the fetal head
begins to emerge from the vagina. C, traction is maintained to lift the fetal
head out of the vagina.
Risks of Forceps
• Monitor FHR during procedure
• Assess newborn for:
– Bruising
– Edema
– Facial lacerations
– Cephalhematoma
– Transient facial paralysis
– Cerebral hemorrhage
Risks of Forceps (cont’d)
• Empty bladder prior to procedure
• Assess patient for:
– Vaginal or perineal lacerations
– Infection secondary to lacerations
– Increased bleeding
– Bruising
– Perineal edema
– Bladder injuries
Application of forceps in occiput anterior (OA) position. A, The left blade is
inserted along the left side wall of the pelvis over the parietal bone. B, The right
blade is inserted along the right side wall of the pelvis over the parietal bone. C,
With correct placement of the blades, the handles lock easily. During uterine
contractions, traction is applied to the forceps in a downward and outward
direction to follow the birth canal.
Indications for Cesarean Section
• Most common indications for cesarean birth
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Fetal distress
Active genital herpes
Multiple gestation (three or more fetuses)
Umbilical cord prolapse
Tumors that obstruct birth canal
Lack of labor progression
Maternal infection
Pelvic size (cephalopelvic) disproportion
Placenta previa or abruptio placenta
Previous cesarean section
Fetal malpresentation
Preparation for C/S
• Preparation for cesarean birth requires
– Obtaining consent
– Obtaining V/S and FHR
– Establishing IV lines
– Inserting indwelling urinary catheter
– Performing abdominal prep
– Maintaining NPO status
– Administering preop
medications
Teaching C/S
• Teaching needs include
– What to expect before, during, and after
delivery
– Why is it being done
– What sensations will the patient experience
– Role of significant others
– Turn, cough, deep breathe instruction
– Early ambulation
– Interaction with newborn
Pfannenstiel
Incision
Classical
Incision
increased risk of uterine rupture in
subsequent pregnancies and labor.
Nursing Care C/S
• Routine postpartal care including:
– V/S and Fundus checks
– Care of incision
– Monitoring intake and output
– Maintain IV access
– Administer and teach about post-op
medications
– Assessment of respiratory system
– Assessment of bowel sounds
Vaginal Birth After Cesarean Birth
• Can occur after trial of labor in cases of
nonrecurring indications for cesarean birth
• Most common risks are
– Hemorrhage
– Surgical injuries
– Uterine rupture
– Infant death or neurological complications
• Classic or T uterine incision is
contraindication to VBAC
Nursing Care for VBAC
• Continuous EFM or Internal Fetal and
Uterine Monitoring
• IV fluids
• Avoid oxytocin if at all possible
• Important for nurse to support couple,
explore their feelings, and provide
information throughout labor
Fetal Demise/Stillbirth
• Results from three factors:
– Fetal factors
• Has or develops disorder incompatible with life
– Maternal factors:
• Has disorder such as diabetes or preeclampsia
that creates hostile environment for fetus
– Placenta or other factors
• Certain conditions such as abruptio placenta or
cord accident cut off blood supply to fetus, leading
to death
Diagnosis of Fetal Loss
• Diagnosis may be made when mother
notices lack of movement in fetus or at
regularly scheduled physician's visit when
fetal heart tone cannot be found
Nursing Care - Fetal Loss
• Nursing care involves supporting family
through grief work
– Assist family through labor and birth
– Provide for woman's physical needs after birth
– Encourage family members to express and
share their thoughts and feelings about loss
– Give family an opportunity to view, hold, name
infant
Nursing Care – Fetal Loss (cont’d)
• Nursing care involves supporting family
through grief work
– Prepare items for family to keep to remember
infant
– Provide opportunities for religious or spiritual
counseling and cultural practices
– Visit or phone family after discharge to assist
in closure
– Make referral to appropriate perinatal loss
counseling services if indicated
NCLEX Question
Nursing assessment of a labor patient
includes: BP 116/72, P 88, contractions q 2
to 3 minutes, duration 75-80 seconds,
resting tone not returning to baseline, FHR
150-156 bpm w/ moderate variability. Which
nursing action is appropriate?
A.
B.
C.
D.
continue present rate of oxytocin
decrease rate of oxytocin
discontinue oxytocin administration
increase rate of oxytocin
NCLEX Question
During the delivery, the fetal shoulders
become stuck behind the symphysis
pubis. What intervention can the nurse
perform to assist with the delivery?
A.
B.
C.
D.
uterine fundal pressure
McRobert’s maneuver
McDonald’s procedure
vacuum suction
NCLEX Question
The nurse assesses uterine contractions as
q 1 – 11/2 minutes frequency and 30
second resting period during an oxytocin
induction. Which is the priority nursing
action?
A.
B.
C.
D.
increase intravenous rate
reposition client to side – lying
notify health care provider
discontinue oxytocin
NCLEX Question
A laboring client is admitted with vaginal
bleeding. Which interventions does the
nurse perform? Select all that apply.
A.
B.
C.
D.
E.
F.
Obtain fetal heart rate
Perform vaginal exam
Start intravenous infusion
Obtain vital signs
Begin oxytocin infusion
Administer oxygen
NCLEX Question
Upon rupture the client has an excessive
amount of amniotic fluid. What problem
would the nurse assess the newborn for?
A.
B.
C.
D.
Respiratory distress
Fractured clavicle
Cephalohematoma
Esophageal atresia
Intrapartum Nursing Diagnoses
• Fatigue related to inability to relax and rest
amb hypertonic labor pattern
• Acute pain related to woman’s inability to
relax amb hypertonic uterine contractions
• Ineffective individual coping related to
ineffectiveness of breathing techniques to
relieve discomfort amb irritability
• Anxiety related to slow labor progress amb
hypotonic contractions
Intrapartum Nursing Diagnoses
• Acute Pain related to uterine contractions
amb complaints of 10/10 pain scale
• Ineffective individual coping related to
unanticipated discomfort and slow
progress in labor amb verbalizations