INTRAPARTAL COMPLICATIONS • Interfe Interferen rence ce with with normal normal proc process esses es & pattern patternss of labor/b labor/birth irth resu resulti lting ng in maternal or fetal fe tal jeopardy. • Preterm Preterm labor; labor; dysfun dysfunctio ctional nal labor labor pattern patterns; s; prolon prolonged ged labor; labor; hemorr hemorrhag hagee – uterine ruputure/inversion; amniotic-fluid embolus. • Dys Dysfunc functi tion onal al Labo abor: • Possible Ca Causes: • Catecho Catecholami lamines nes (respo (response nse to anxiety anxiety/fea /fear), r), increas increasee physical/psychological stress, leads to myometrial d ysfunction; painful & ineffective labor. labor. • Prematu Premature re or exces excessiv sivee analges analgesia, ia, partic particula ularly rly duri during ng laten latentt phase. phase. • Maternal fa factors. • Fetal factors. • Placen cental facto ctors. • Physi Physica call rest restri ricti ction onss (pos (posit itio ion n in bed) bed).. • ASSESSMENT: • Ante Antep parta artall his history tory.. • Emotio tional status. • Vital signs, FHR. • Contrac Contractio tion n pattern pattern (freque (frequency ncy,, durati duration, on, intens intensity ity). ). • Vagin aginal al dis dischar charg ge. GOAL = to minimize physical / psychological stress during labor/birth. Emotional support. • Preterm Labor: • Occurs Occurs after after 20 weeks weeks gestati gestation on and before before 38 weeks. weeks. • Causes Causes may be from from materna maternal, l, fetal fetal,, or placen placental tal facto factors. rs. • Prevention: • Primary Primary:: close close obser observati vation on and and educt eduction ion in S&S S&S of of labor labor.. • Second Secondary ary:: prompt prompt,, effecti effective ve Rx of associ associated ated disord disorders ers.. • Tertia ertiary ry:: supp suppres ressi sion on of prete preterm rm labo laborr. • Tertia ertiary ry:: supp suppres ressi sion on of prete preterm rm labo labor r • Bedrest. • Positi Position: on: side-ly side-lying ing – to promot promotee place placental ntal perfus perfusion ion.. • Hydration. • Pharma Pharmacol cologi ogical: cal: betaadr betaadrene energ rgic ic agent agentss to redu reduce ce sensi sensitiv tivity ity of of uterin uterinee myometrium to oxytocic & prostaglandin stimulation; increase bld flow to uterus. • Pt may be maint maintain ained ed at home home with with adequ adequate ate follo follow-u w-up p & health health teach teaching ing.. • CONTRA CONTRAIND INDICA ICATIO TIONS: NS: for suppre suppressi ssion on of labor labor • Place Placent ntaa prev previa ia or abru abrupt ptio io plac placen enta. ta. • Chorioamn amnionitis tis. • Ery Erythro throbl blas asto tosi siss feta fetali lis. s. • Severe pre preecla clampsia. • Seve Severe re diab diabet etes es (bri (britt ttle le). ). • Incre Increas asin ing g place placent ntal al ins insuf uffic ficien iency cy.. • Cerv Cervic ical al dil dilat atio ion n of of 4 cm cm or or mor more. e. • ROM ROM (dep (depen ends ds on on caus causee & if sep sepsi siss exis exists ts). ). • Nurs Nursin ing g Ass Assess essmen ment: PTL • Mater Maternal nal VS. VS. Resp Respon onse se to medi medicat catio ion: n:
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• Hypotension • Tachy achyca card rdia ia,, arrh arrhy ythmi thmiaa • Dys Dyspnea, ea, chest pain ain • Nausea & vomiting Signs of infect fectiion: • Incr Increa eassed tem tempera peratu ture re • Tachycardia • Diaphoresis • Malaise
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Emotio Emotional nal status status:: denial, denial, guilt, guilt, anxiety anxiety,, exha exhaus ustion tion.. Sign Signss of cont contin inui uing ng & prog progres ressi sing ng lab labor or:: • Effacement • Dilation • Station (vaginal exam ONLY ONLY if indicated by other signs of continuing labor progress) • Status tus of of me membrane anes. • FHR, FHR, act activi ivity ty (co (cont ntin inuo uous us mon monito itorin ring) g).. • Ctx: Ctx: frequ frequen ency cy,, dura duratio tion, n, stren strengt gth. h. • • • • • • •
Repo Report rt PROMP ROMPT TLY to to MD: MD: Mate Matern rnal al puls pulsee of of 110 110 or more more.. Dias Diasto tolic lic pres pressu sure re of 60 mmHg mmHg or less less.. Incr Increa ease se in in mate matern rnal al tem tempe pera ratu ture re.. Resp Respira iratio tions ns of of 24 or or more; more; crac crackl kles es (ra (rales les). ). Comp Compla lain intt of dys dyspnes pnes.. Contractions Contractions:: increasin increasing g frequency frequency,, strength strength,, duration, duration, or cessatio cessation n of of ctx. ctx.
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Inte Interm rmit itte tent nt bac back k and and thig thigh h pain pain.. Rupt Ruptur uree of mem membran branes es.. Vagi aginal bl bleeding. Fetal distress.
IF LABOR CONTINUES: • • • • • • •
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GOAL GOAL = facilita facilitate te infant infant survi survival; val; emoti emotiona onall suppor support; t; suppor supportt comfort comfort measures; health teaching. Dysfunctional Labor Pattern Hypertonic la labor Hypotonic labor Prec Precip ipit itat atee lab labor or leve levell HYPE HYPER RTONIC ONIC DYSF DYSFUN UNCT CTIO ION: N: Increas Increased ed resting resting tone tone of uterine uterine myomet myometriu rium; m; dimini diminishe shed d refractory refractory perio period; d; prolonged latent phase. • Nullipara: Nullipara: more than 20 hours. • Multipara: Multipara: more than 14 hours. Etiolog Etiology: y: unknow unknown. n. Theory Theory – ectop ectopic ic initi initiatio ation n of incoo incoordi rdiante ante uterin uterinee ctx. ctx. Assessment: • Onset (earl early y labo abor)
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Contractions: • Contin Continuou uouss fund fundal al tens tension ion,, inco incompl mplete ete relaxat relaxation ion.. • Painful. • Inef Ineffe fectu ctual al – no effac effaceme ement nt or or dila dilatio tion. n. • Sig Signs of feta fetall dis distr tres ess: s: • Meco Mecon nium ium-sta -stain ined ed flu fluid id.. • FHR ir irregu egulariti ritiees. • Maternal VS VS. • Emotion ional stat tatus. • Medi Medical cal evalu evaluati ation on:: to rule rule out out CPD. CPD. • Vaginal aginal examina examinatio tion, n, x-ray pelvim pelvimetry etry,, ultrasono ultrasonogra graphy phy.. Inter Interve vent ntio ions ns with with Hype Hyperto rtoni nicc Dysfu Dysfunc ncti tion on:: Short-a Short-actin cting g barbi barbitur turates ates (to enco encourag uragee rest, rest, relax relaxatio ation). n). IV fluid fluidss (to resto restore re / maintain maintain hyd hydrati ration on & fluidfluid-elec electro trolyt lytee balance). balance). If CPD – c/s. Prov Provid idee emo emoti tion onal al supp suppor ort. t. Prov Provid idee comf comfor ortt meas measur ures es.. Prev Preven entt infect infectio ion n (stric (strictt asept aseptic ic tech techni niqu que). e). Prep Prepar aree pati patien entt for for c/s c/s if if need needed ed.. HYPO HYPOT TONIC NIC DYSF DYSFUN UNC CTION TION:: After normal normal labor at onset, onset, ctx diminis diminish h in frequency frequency,, duration duration,, & strength. strength. Lowered Lowered uteri uterine ne restin resting g tone; tone; cervic cervical al efface effacemen mentt & dilatio dilation n slow slow / cease. cease. Etiology: • Prematu Premature re or excess excessive ive analge analgesia sia / anesth anesthesi esiaa (epidura (epidural, l, spinal spinal block block). ). • CPD. • Overdi Overdiste stentio ntion n (hydramn (hydramnios ios,, fetal macroso macrosomia, mia, multi multifeta fetall pregnancy pregnancy). ). • Fetal Fetal malp malpos osit itio ion n / malp malpres resen entat tatio ion. n. • Mate Matern rnal al fear fear / an anxiet xiety y. Assessment: • Onset Onset (late (latent nt phas phasee & most most comm common on in in activ activee phas phase). e). • Contrac Contractio tions ns - normal normal previo previously usly,, will will demo demonst nstrate rate:: • Decr Decrea ease sed d freq freque uen ncy. cy. • Shorter durati ation. • Dimin Diminis ishe hed d inten intensi sity ty (mi (mild ld to to mode modera rate) te).. • Less un uncom comforta rtable. • Cerv Cervic ical al chan change gess – slow slow or ceas cease. e. • Sign Signss of of fet fetal al dist distre ress ss – rar rare. e. • Usually Usually late in labor labor d/t infe infectio ction n secon secondary dary to prolo prolonge nged d ROM. • Tachycardia. • •
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Maternal Maternal VS (elev (elevated ated temper temperatur ature) e) – may may indic indicate ate infe infectio ction. n. Medical Medical diagno diagnosis sis – proce procedur dures: es: vagi vaginal nal exam examina inatio tion, n, x-ray x-ray pelvimetry, pelvimetry, ultrasonography. ultrasonography. To rule out CPD (most common cause). Management: • Amni Amniot otom omy y (art (artif ific icia iall ROM) ROM).. • Oxyt Oxytoc ocin in augm augment entat atio ion n of labo laborr. • If CPD, PD, prep repare are for for c/s. c/s.
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• Emotio Emotional nal supp support ort,, comfor comfortt measur measures, es, prev prevent ent infe infectio ction. n. Precipitate La Labor Labor that progresses progresses rapidly and ends with the delivery delivery occurring occurring less than 3 hours after the onset of uterine activity activit y. Rapi Rapid d labo laborr and and deli delive very ry.. Fetal Malpresentation and Malposition Breech ech pre pressent entati ation Shou Should lder er pres resenta entati tion on Face pr presentation Malpositions Bree Breech ch Pres resenta entati tion onss Fetal Fetal descen descentt in which which the fetal fetal butt buttock ocks, s, legs, legs, feet, feet, or or combina combinatio tion n of these these parts is found first in the maternal pelvis. Labor tends to be be longer longer and more more diffic difficult ult due due to a softer softer present presenting ing part, that does not fill the birth canal completely. Incr Increa ease se risk riskss for for fet fetal al out outco come me.. Shou Should lder er Pres resenta entati tion on Fetal Fetal descen descentt in which which the shou shoulde lderr precedes precedes the the fetal fetal head head in the mater maternal nal pelvis alone or along with the ftal arm and hand. Vagin aginal ally ly unde undeli live vera rabl ble. e. Face Pr Presentation Fetal Fetal descen descentt in which which hyper hyperext extens ension ion of of the fetal fetal head head and neck neck allow allowss the fetal face to descend into the maternal pelvis, as opposed to flexion that results in fetal vertex presentation. Brow Brow presen presentati tation on = occurs occurs when when the the area area between between the the anterio anteriorr fontan fontanelle elle and and the fetal eyes descends first. Malpositions Pers Persis isten tentt occip occipito itopo post ster erio iorr posi positi tion on.. Pers Persis isten tentt occip occipito itotr tran ansv svers ersee positi position on.. Result Result from from fetal fetal rota rotatio tion n as the the fetus fetus desce descends nds throug through h the pelv pelvis. is. Possib Possible le precipi precipitati tating ng factor factorss are macros macrosomi omiaa and pelvic pelvic abnor abnormali malities ties.. Results Results in increased increased discom discomfort fort (particularly (particularly back labor), labor), prolon prolonged, ged, abnormal abnormal labor, soft tissue injury, injury, lacerations, or an extensive episiotomy incision. Maternal and Fetal Structural Abnormalities Ceph Cephalo alope pelv lvic ic disp dispro ropo port rtio ion n (CPD (CPD)) Macrosomia DYSTOCIA: Difficult la labor. Causes: • “3 Ps” Ps” for for moth mother: er: Psyc Psych, h, Plac Placent enta, a, Posi Positi tion on.. • “3Ps” “3Ps” for for fetu fetus: s: Pow Power er,, Pass Passagew ageway ay,, Passe Passenge ngerr. POWER: POWER: forces forces of of labor labor (uteri (uterine ne contr contracti actions ons,, use use of abdo abdomin minal al muscle muscles). s). • Prem Premat atur uree anal analge gesi siaa / anes anesth thes esia ia.. • Uterine Uterine over overdis disten tensio sion n (multif (multifetal etal preg pregnan nancy cy,, fetal macro macrosom somia) ia) • Uterine myomas. PASSAGEW ASSAGEWA AY: Resistance Resistance of cervix, cervix, pelvic structures. structures. • Rigid ce cervix. • Disten tended bl bladder. er. • Distended re rectum.
• Dimensi Dimensions ons of the the bony bony pelvi pelvis: s: oelvic oelvic contrac contractur tures. es. • PASSENG ASSENGER: ER: accommo accommodat dation ion of the the prese presenti nting ng part part to to pelvi pelvicc diamet diameters ers.. • Fetal Fetal malp malpos osit itio ion n / malp malpres resen entat tatio ion. n. • Fetal anomalies. • Fetal size. • Haza Hazard rdss with ith Dys Dystoci tocia: a: • MATERNAL: 1. Fatigue, exhaustion, dehydration. 2. Lowered pain threshold, threshold, loss of control. 3. Intrauterine infection. 4. Uter Uterin inee rupt ruptur ure. e. 5. Cervica Cervical, l, vagina vaginal, l, perine perineal al lacerati lacerations ons.. 6. Post Postpa part rtum um hemo hemorrh rrhag age. e. • FETAL: 1. Hypo Hypoxi xia, a, anox anoxia, ia, demi demise se.. 2. Intr Intracr acran ania iall hemor hemorrh rhag age. e. • Placental Abnormalities • Placenta pr previa • Abrup ruptio plac lacent entae • Othe Otherr pla place cent ntal al abno abnorm rmal alit itie iess • PLACENTA PREVIA • Abnorm Abnormal al placem placement ent of of placen placenta ta so that that it parti partially ally cove covers rs the the cervix; cervix; dilatation results in bleeding, which can be of hemorrhagic proportions. • The place placenta nta is is located located over over or very very near near the the intern internal al cervi cervical cal os. os. • Severe Severe hemor hemorrha rhage ge can resu result lt from from digital digital palp palpatio ation n of the inte interna rnall os. • Previa Previa is a serio serious us but but uncomm uncommon on compl complicat ication ion,, occurri occurring ng in .3-.5 .3-.5% % of pregnancies. • • • • • •
Advanc Advanced ed mate maternal rnal age and multip multiparit arity y increa increase se the the risk risk.. Painles Painlesss hemorr hemorrhag hagee is sympt symptoma omatic tic of previ previa, a, often often aroun around d the end end of the the 2 nd trimester. Clinica Clinicall diagnos diagnosis is is reache reached d through through ultr ultraso asound und exam examina inatio tion n in which which the placenta is localized in relationship to the cervix. Manu Manual al exa exami mina nati tion on is con contra train indi dica cated ted!! Managem Management ent of preg pregnan nancy cy depend dependss on gestati gestationa onall age. age. PLAC PLACE ENTAL NTAL ABRU ABRUPT PTIO ION N
Grading of Placental Abruptions: • Grade I: Slight Slight vag.bleedin vag.bleeding g & some uterine uterine irritability irritability.. Maternal Maternal BP is unaffected & there are normal fibrinogen fibrinogen levels. FHR has a normal pattern. • Grade II: External External bleeding bleeding is mild to moderate. moderate. The uterus is irritable. irritable. Tetanic ctx may be present. Maternal BP is maintained. FHR shows signs of distress. Maternal fibrinogen level is decreased.
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Grade III: The bleeding bleeding may be severe severe & may be concealed concealed in some instances. Uterine ctx are tetanic and and painful. Maternal hypotension hypotension may be present. The fibrinogen level is greatly decreased & there are coagulation problems.
Diagnosis: may be made by ultrasound, but frequently the diagnosis is made made and confirmed at delivery deliver y, by inspection of the placenta. • Umbilical Cord Abnormalities • Velame elament ntou ouss ins insert ertio ion n of of the the cord cord • Umbi Umbili lica call cord cord comp compre ress ssio ion n • Umb Umbilic ilical al cord cord prol prolap apsse • Velame elament ntou ouss Ins Insert ertio ion n of of the the Cord Cord • Condit Condition ion wher wheree the umbil umbilical ical cord cord joins joins the the placen placenta ta at the edge edge,, rather rather than than the typical insertion in the center. • Can result result in in chron chronic ic altere altered d fetal fetal perf perfusi usion on.. Can lead to trau trauma ma and and compression during L&D, resulting in rupture and hemorrhage. PROLAPSED UMBILICAL CORD: • Cord descent descent in advance advance of presenting presenting part; compression compression interrupts interrupts blood flow, flow, exchange of fetal / maternal gases. Leads to fetal hypoxia, hypoxia, anoxia, death (if unrelieved). • Etiology: • SROM or AROM. • Excess Excessive ive force force of escapin escaping g fluid fluid (hydram (hydramnio nios). s). • Malposi Malposition tion (bre (breech ech,, compoun compound d presen presentati tation, on, tran transve sverse rse lie). lie). • Preterm Preterm or SGA SGA fetus fetus – allows allows spac spacee for for cord cord desc descent ent..
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Assessment: • Visualiz isualizatio ation n of of cord cord outs outside ide (or inside inside)) vagin vagina. a. • Palp Palpati ation on of of puls pulsati ating ng mas masss on vag vagina inall exam exam.. • Fetal Fetal distres distresss – variabl variablee decelera deceleratio tion n and pers persist istent ent brady bradycard cardia. ia. Nurs Nursin ing g int inter erve ven ntio tions: ns: • Redu Reduce ce pres ressure sure on co cord. rd. • Increas Increasee matern maternal al / fetal fetal oxyge oxygenati nation on (O2 (O2 per per mask mask @ 8-10 8-10 liters) liters).. • Protect Protect expo exposed sed cord cord (cont (continu inuous ous pres pressu sure re on prese presenti nting ng part part to keep keep pressure off cord). •
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Identif Identify y fetal fetal resp respons onsee to thes thesee measu measures res,, reduce reduce thre threat at to fetal fetal survival: moniotr FHR continuously. continuously. • Expedi Expedite te termin terminatio ation n of threat threat to to fetus fetus (prep (prepare are for for immedi immediate ate vagin vaginal al or c/s). • Suppor Supportt mother mother and and sign signifi ificant cant othe otherr (try to explai explain n things things while while mobilizing delivery team). Amniotic Fluid Abnormalities Polyh lyhydramnios Oligohydramnios Amn Amniot iotic flu fluid emb embolis olism m Summ Summary ary of Dang Danger er Sig Signs ns Duri During ng Labo Labor: r: Contrac Contractio tions: ns: strong strong,, every every 2 min. min. or or less, less, last lasting ing 90 90 sec. sec. or or more; more; poor poor relaxation between ctx. Sudden Sudden shar sharp p abdomi abdominal nal pain pain follo followed wed by by boardl boardlike ike abdom abdomen en and and shock shock (abruptio placenta or uterine rupture). Mark Marked ed vagin aginal al ble bleed edin ing. g. FHR period periodic ic patter pattern n decele decelerati rations ons – late; late; varia variable ble;; absent absent..
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Baseline FH FHR: • Brad Brady ycard cardia ia (<100 <100 bpm) pm) • Tachy achyca card rdia ia (>16 (>160 0 bpm bpm)) Amniotic fluid: • Amou Amount nt:: exce excess ssiv ive; e; dimi dimini nish shed ed.. • Odor • Color: Color: meconi meconium um staine stained d or or parti particul culate; ate; port-w port-wine ine;; yello yellow w. • 24 hr or more ore sin since ce ROM ROM. Mate Matern rnal al hyp hypoten tensio sion. POST POSTP PARTU ARTUM M COMP COMPLI LICA CATI TION ONS S Chapter 37 Post Postp partu artum m Hem Hemor orrh rhag age: e: Definition: • More More than than 500c 500ccc of blood blood loss loss after after vagina vaginall birth birth.. • More More tha than n 100 1000c 0ccc of of bloo blood d loss loss after after C/S C/S.. Blood Blood los losss is often often underes underestim timated ated by up up to 50% 50% (ACOG (ACOG,, 1998) 1998).. Subjec Subjectiv tive. e. #1 cau cause se of of PP Hemo Hemorrh rrhag agee = Uteri Uterine ne Atony Atony..
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Risk Risk Fact Factor orss for for PP PP Hem Hemor orrh rhag age: e: Uterine Uterine Atony Atony: Marked Marked hypoto hypotonia nia of of the uterus uterus • Over Overd diste istend nded ed uteru teruss • Anes Anesth thes esia ia an and an analg algesia esia • Prev Previo ious us hist history ory of uteri uterine ne aton atony y • High parity • Prol Prolon onge ged d labor labor,, oxyto oxytocin cin-in -indu duced ced lab labor or • Traum raumaa dur durin ing g lab labor or and and bir birth th
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Risk Risk Fact Factor orss for for PP PP Hem Hemor orrh rhag age: e: Lace Lacera rati tion onss of of the the birt birth h can canal al Reta Retain ined ed plac placen enta tall fra fragm gmen ents ts Ruptured uterus Inve Invers rsio ion n of of th the ute uteru russ Placenta accreta Coag Coagul ulat atio ion n disor isord ders ers Placen cental abruption Risk Risk Fact Factor orss for for PP PP Hem Hemor orrh rhag age: e: Placenta pr previa Manu Manual al remov removal al of a reta retain ined ed place placent ntaa Magnes Magnesium ium sulf sulfate ate admin administ istrati ration on durin during g labor labor or postp postpartu artum m period period Endometritis Uter Uterin inee subin ubinvo volu luti tion on Lacerations:
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Cerv Cervix ix,, vagi vagina na,, peri perine neum um.. Suspected Suspected when bleeding bleeding continues continues despite despite a firm, contracted contracted uterine uterine fundus fundus.. Charact Characteris eristic tics: s: bleedi bleeding ng can can be be a slow slow trickle trickle,, an oozing oozing,, or frank frank hemorrhage. Influe Influencin ncing g factors factors:: struct structura ural, l, matern maternal, al, fetal fetal Lacerati Lacerations ons = the the most most common common caus causee of injuri injuries es in the the lower lower portio portion n of the genital tract.
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Retai tained Place acenta:
Causes: • • • •
Parti Partial al sepa separat ratio ion n of of nor norma mall pla placen centa ta Entrapm Entrapment ent of of the partia partially lly or comp complete letely ly separ separated ated place placenta nta by uterine uterine constriction ring Mism Misman anag agem emen entt of the the 3rd stage of labor Abnorm Abnormal al adheren adherence ce of the the entir entiree placent placentaa or a portio portion n of place placenta nta to to the uterine wall
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Nona Nonadh dher eren entt ret retai aine ned d pla place cent ntaa Adhe Adhere rent nt reta retain ined ed plac placen enta ta
Inve Invers rsio ion n of of th the Ute Uteru russ Rare, but life threatening. threatening. (1 in 2000-2500 2000-2500 births). births). May recur with additional additional births. Cont Contri rib butin uting g fact facto ors: rs: • Fund Fundal al imp impla lant ntat atio ion n of pla place cent ntaa • Vigor igorou ouss fund fundal al pres pressu sure re • Exces Excessi sive ve tract tractio ion n appl applied ied to cord cord • Uterine atony • Leiomyomas • Abno Abnorm rmall ally y adh adher erent ent place placent ntal al tissu tissuee Uter Uterin inee Subi Subin nvolu voluti tio on Causes: • Reta Retain ined ed plac placen enta tall fra fragm gmen ents ts • Pelvic infection Signs an and sy symptom toms: • Prol Prolon onge ged d loc lochi hial al disc discha harrge • Irre Irregu gula larr or exce excess ssiv ivee blee bleedi ding ng • Hemorrhage • Pelvic Pelvic exam exam reveals reveals a uteru uteruss that that is larger larger than than normal normal and may be boggy
