Complications of Labor and Delivery
Barbara A. Evans, RN, MSN Aquinas College ASN Program Fall 2009
Crucial for Nurses to: • Understand normal birth process • Prevent and detect deviations from normal labor and birth • Implement nursing measures if complications arise
Essential Forces of Labor • Powers • Passage • Passenger • Psyche
Problems with the Powers • Dysfunctional Labor -“abnormal uterine contractions that prevent the normal progress of cervical dilation, effacement or descent.” Wong, et al (2006)
Ineffective Uterine Forces
• Hypotonic Contractions • Hypertonic Contractions • Ineffective Contractions
Hypotonic Contractions Also called Secondary Uterine Inertia Usually in Active Phase of labor • Maternal Effects • Fetal Effects • Medical Treatment • Nursing Care
Hypertonic Contractions Primary Dysfunctional Labor • Maternal Effects • Fetal Effects • Medical Treatment • Nursing Care
Ineffective Contractions
• Maternal Effects • Fetal Effects • Medical Treatment • Nursing Care
First Stage Dysfunction
• Prolonged Latent Phase • Prolonged Active Phase • Prolonged Descent • Prolonged Labor
Prolonged Labor Labor that lasts more than 24 hours (latent/active phase combined) • Maternal Effects • Fetal Effects • Medical Treatment • Nursing Care
Second Stage Dysfunction • Arrest of Descent • Failure of Descent • Dystocia Will discuss in more detail later
Precipitous Labor
“an intense, unusually short labor (less than 3 hours)” Maternal-Child Nursing (2000)
Precipitate Labor
• Maternal Implications • Fetal Implications • Medical Treatment • Nursing Care
Post Dates Pregnancy
• Pregnancy that lasts > 42 weeks • Physical risk to fetus • Utero-placental insufficiency • Respiratory Distress of newborn • Growth restriction of fetus
Uterine Rupture
• Very serious obstetric injury • Most frequent causes • Separation of scar of previous classic cesarean birth • Uterine trauma: accidents, surgery • Congenital uterine anomaly
Uterine Rupture
• Causes • Signs/Symptoms • Maternal Effects • Fetal Effects • Management • Complications
Uterine Inversion
Defined as “when the uterus completely or partly turns inside out, usually during the 3rd stage of labor.” Maternal-Child Nursing (2000)
Amniotic fluid embolism (AFE)
• Amniotic fluid containing particles of debris • Vernix, hair, skin cells, or meconium enters maternal circulation • Obstructs pulmonary vessels • Causes respiratory distress and circulatory collapse
Amniotic Fluid Embolism
• Maternal Effects • Fetal Complications • Medical Treatment • Also termed “Anaphylactoid Syndrome of Pregnancy”
Problems with the Passenger • Prolapse of Umbilical Cord • Multiple Gestation • Fetal Malpresentation • Macrosomia • Shoulder Dystocia
Prolapsed umbilical cord • When cord lies below presenting part of fetus • Contributing factors include: • Long cord (longer than 100 cm) • Malpresentation (breech) • Transverse lie • Unengaged presenting part
Prolapse of Umbilical Cord Note pressure of presenting part on umbilical cord, which endangers fetal circulation A. Occult (hidden) prolapse of cord B. Complete prolapse of cord. Note that membranes are intact C. Cord presenting in front of fetal f etal head may be seen in vagina D. Frank breech presentation with prolapsed cord
Prolapsed Umbilical Cord
• Maternal Effects • Fetal Effects • Medical Treatment • Nursing Care
Multiple Gestation • Twins 1/99 • Triplets 1/500 • Quads 1/400,000 • • • •
Maternal Effects Fetal Effects Medical Treatment Nursing Care
External Version of Fetus from Breech to Vertex Presentation This must be achieved without force A. Breech is pushed up out of pelvic inlet while head is pulled toward inlet B. Head is pushed toward inlet while breech is pulled upward A
B
Fetal Malpositions and Malpresentations • Maternal Implications • Fetal Effects • Medical Treatment • Nursing Care
Macrosomia • Macro = large • Soma = body • >9.5 lbs • Common in IDM babies
Macrosomia
• Maternal Effects • Fetal Effects • Medical Treatment • Nursing Care
Shoulder dystocia • Head is born, but anterior shoulder cannot pass under pubic arch • Newborn is more likely to experience birth injuries • Mother’s primary risk stems from excessive blood loss, lacerations, extension of episiotomy, or endometritis
Application of Suprapubic Pressure A. Mazzanti technique: pressure is applied directly posteriorly and laterally above the symphysis pubis B. Rubin technique: pressure is applied obliquely posteriorly against the anterior shoulder
A
B
McRoberts Maneuver
Problems with the Passage Dystocia Pelvic dystocia Contractures of pelvic diameters that reduce the capacity of the bony pelvis, inlet, midpelvis, or outlet Soft-tissue dystocia Results from obstruction of the birth passage by an anatomic abnormality other than the bony pelvis
Therapeutic Management of Problems/Potential Problems • Cervical Ripening • Cytotec
• Induction of Labor • Amniotomy • Oxytocin Infusion
• Augmentation of Labor
Induction/Augmentation of Labor Induction/Augmentation • 2 types • Elective • medical
• Contraindications • Assessment for readiness • Fetal • Maternal
• Augmentation
Amniotomy
• Disadvantages • Advantages • Nursing Responsibilities
Oxytocin Infusion
• IV for induction • Begin at 0.5-2mu/min • Increase 0.5-2mu/min every 15-60 minutes • Risks of Administration • Nursing Care
Other Complications • Oligohydramnios • Polyhydramnios • Intrauterine Fetal Death
Oligohydramnios • Defined as < 500ml between 32 and 36 weeks gestation • Common Causes • Maternal and Fetal Effects • Medical Treatment • Nursing Implications and Care
Hydramnios or Polyhydramnios
• Defined as exceeding 2 Liters between 32 and 36 weeks gestation • Association with condition • Maternal and Fetal Effects • Medical Treatment • Nursing Care
Intrauterine Fetal Death (IUFD) Physical and Psychological Concerns
Assessment Medical Treatment Nursing
Interventions
Instrumental Deliveries • Forceps Delivery
Care Management Forceps-assisted birth Maternal indications Shorten second stage in event of dystocia Compensate for deficient expulsive efforts Reverse a dangerous condition Fetal indications Distress or certain abnormal presentations presentations Arrest of rotation Delivery of head in a breech presentation
Outlet forceps–assisted extraction of the head
Types of forceps Piper forceps are used to assist delivery of the head in a breech birth
Tucker-McLean
Instrumental Deliveries • Forceps Delivery • Vacuum Extraction
Care Management Vacuum-assisted birth Attachment of vacuum cup to fetal head, using negative pressure to assist birth of head Prerequisites Vertex presentation Ruptured membranes Absence of CPD
Use of Vacuum Extraction to Rotate Fetal Head and Assist with Descent A. Arrow indicates direction of traction on the vacuum cup B. Caput succedaneum formed by the vacuum cup
Fetal Distress Reassuring Patterns Non-Reassuring Patterns Fetal Scalp Stimulation Physiological Goals and Nursing Interventions
Fetal Heart Rate • Characteristic Patterns • Tachycardia • Bradycardia
• Variability • Absent • Minimal • Moderate
• Decelerations (late and variable) • Interventions
Cesarean Birth • Why?
• Preop
• Scheduled
• Assessment
• Emergency
• VS • Lab Studies • Teaching • Consent • Prep for Surgery • Preop meds • Support person
Cesarean Birth: Skin and Uterine Incisions A. Classic: vertical incisions of skin and uterus
B. Low cervical: horizontal incision of skin; vertical incision of uterus
C. Low cervical: horizontal incisions of skin and uterus
Bibliography • Feinstein, N. Torgersen, K. L., & Alterbury, J. (2003). Fetal Heart Monitoring Principles and Practices. Kendall/Hunt Publishing Company: Dubuque, IA. • Mattson, S. and Smith, J. E., (2000). (2000). Core Curriculum Curriculum for Maternal-Newborn Nursing. W. B. B. Saunders Saunders Company: Company: Philadelphia • McKinney, E. S., Ashwill, J. W., Murray, S. S., James, S. R., Gorrie, Gorrie, T. M. & Droske, S. C. (2000). Maternal-Child Nursing, W. B. B. Saunders Saunders Company: Company: Philadelphia. • Pilliterri, A. (2002). (2002). Maternal & Child Health Health Nursing (4 th ed.). Lippincott: Philadelphia .
Bibliography • Wong, D. L., Hockenberry, M. J., Perry, S. E., Lowdermilk, D. L., & Wilson, Wilson, D. (2006). Maternal Child Nursing Care (3rd ed.). Mosby: St. Louis, MO. • www.fetalmonitorstrips.com/learn_more.html
