Complications of Labor and Delivery
by: Ann Hearn, MSN, RNC
Complications of Labor and Delivery
by: Ann Hearn, MSN, RNC
The PowersIneffective ContractionsUterine Dystocia -defined as difficult labor.
Hypotonic contractions – coordinated, infrequent, weak, brief, mildly painful.
Hypertonic contractions – uncoordinated and erratic in frequency, duration and intensity; Painful.
Interventions for Uterine DystociaHypotonic Uterus: results from overstretched
uterine muscle leading to a prolonged active phase.
Nursing Interventions:Position changes, ambulationEmptying bladderAmniotomyPitocin administrationHydrationTeaching/Support
Interventions for Uterine DystociaHypertonic Uterus: Contractions are painful
but ineffective resulting in prolonged latent phase.
Nursing Interventions:Bed restSedation or pain reliefPosition changesSupport/educateComfort measures: calm environment, music,
therapeutic touch, back rub, warm shower, imagery
Ineffective Pushing.If pushing is ineffective, correct the cause.
Incorrect techniquesFear of injuryMinimal or no urgeMaternal exhaustionRegion block Psychological unreadiness
There is no time limit for 2nd Stage
The Passenger
Problems with the PassengerFetal Size
Shoulder dystociaPresentation
Fetal liePosition
Assisted deliveryMulti-fetalFetal anomalies
Three Malpresentations1. Brow: forehead
C/S delivery
2. Face Vaginal delivery
3. Breech• Frank – buttocks• Footling – foot/feet C/S delivery
The Passage WayPelvis
Size & shapeBladder
The PsychePainStressFearNon-support
Failure to ProgressProlonged LaborCauses:
Labor dystociaMalpositionMalpresentationMacrosomia
Interventions:R/O CPDUterine restPitocin augmentation
Friedman’s Curve
Precipitous LaborLabor < 3 hours from onsetComplications:
Woman loss of coping ability Lacerations of cervix, vagina, perineum
Fetus Hypoxia Cerebral trauma Pnemothorax
Precipitous LaborMonica, a G1, P0 @ 39.4wks is admitted to L&D with
occasional uterine contractions that started soon after her BOW broke an hour ago. She pauses during conversation to breath during contractions and gives a pain rating of 5. Monica states she will probably want an epidural.
While performing the admission history/assessment you notice that Monica’s contractions are occurring every 2 minutes and palpate strong. Monica is beginning to demonstrate difficulty with coping during contractions. Monica grunts during her last contraction.
What nursing interventions will you provide?
Nursing Care in Dysfunctional Laborintrauterine infection
Identify s/sReduce risk
Assist with exhaustionConserve energyPromote coping skills
Premature Rupture of Membranes - PROMSpontaneous rupture of membranes prior to
the onset of laborAssociated conditions:
InfectionPrevious history of PROMHydramniosMultiple pregnancyUTITrauma
Premature Rupture of Membranes - PROMDetermine time of PROMVerification of PROM:
VisualizationSterile speculum exampH
Premature Rupture of Membranes - PROMNursing Assessment
Vital signs (temp q 2hr)Fetal monitoringNature of fluidWBC count
PPROM: PretermCelestone - betamethasoneAntibiotics
If leak seals, discharge instructions
Preterm LaborDefined as: labor that occurs between 20 and
37 weeks gestation.Associated conditions
Multiple gestationHydraminosUTIAbdominal traumaInfectionNo prenatal careLow socio-economic status
Preterm LaborPrevention of PTL
Education Diagnosing PTL:
Fetal Fibronectin test (fFN) 99% accurate predictor of NO preterm birth within
7 days
Preterm LaborTocolytics: Tocolytics: Medications prescribed to stop preterm labor
Magnesium sulfate – CNS depressantNifedipine – Calcium channel blockerIndomethacin – Prostaglandin synthesis
inhibitorTerbutaline – B adrenergic receptor agonist
Tocolytic Drugs - Smooth Muscle Relaxants. Magnesium Sulfate Contraindications: discontinue for resp. depression, magnesium level >8, administer ca+ gluconate
Side Effects: flushing, headache, nausea, lethargy, dizziness, decreased DTR, decreased resp. rate, pulmonary edema
Nifedipine Contraindications: kidney or liver disease (especially cirrhosis), coronary artery disease, congestive heart failure, or digestive problems
Side Effects: flushing, headache, orthostatic hypotension, transient maternal/fetal tachycardia
Terbutaline Contraindications: hold and notify HCP if mat. HR > 120bpm
Side effects: increase heart rate, feeling of anxiety, headache, increased blood glucose
Indomethacin Contraindications: given X48-72 hoursSide effects: constriction of PDA, prolong bleeding, N/V, heartburn,
rash
Nursing Management for the Woman in Preterm Labor
Nursing ImplicationsPromote rest, hydration, circulationMonitor FHR and uterine activity
SupportMedical therapy
TocolyticsSteriodsAntibiotic
Adherence to therapy
Prolapsed Umbilical CordOccurs when the umbilical cord precedes the
presenting part.Primary Risk Factor
Fetal head is not engaged or at a high station
Vessels carrying blood to & from the fetus are compressed, usually results in fetal distress or possible demise
Nursing InterventionsKnee chest positionAdminister O2Manual lift of fetal head off the cord
Variations of Prolapsed Umbilical Cord
Fig. 27-6a
Variations of Prolapsed Umbilical Cord (cont’d)
Fig. 27-6c
Ruptured UterusCauses:
Long difficult laborInjudicious use of PitocinPrevious C/S
Assessment FindingsFetal bradycardiaMaternal abdominal pain
Obstetrical TreatmentEmergency Cesarean Section delivery
Uterine Rupture
Anaphylactoid Syndrome: Amniotic Fluid Embolism
In the presence of a small tear in the amnion and chorion, a small amount of amniotic fluid may leak into the chorionic plate and enter the maternal blood system.
Can also occurs at areas of placental separation, cervical tears or during trumultuous labor
The more debris (meconium, vernix, lanugo) in the amnionic fluid, the greater the maternal problems caused by possible anaphylactic reaction to fetal antigens
Amniotic Fluid EmbolismAssessment Findings: Sudden onsetRespiratory distress (dyspnia)Circulatory collapse (cyanosis)TachycardiaHypotension Acute hemorrhageCor PulmonaleFrothy sputum
Amniotic Fluid EmbolismObstetrical EmergencyInterventions:
Large bore IV linePositive pressure oxygenCPRBlood transfusion - DICEmergency C/S if pregnant
Prognosis – 50% of women die with the first hour of symptoms
Amniotomy/Artificial Rupture of Membranes (AROM)
Advantages:Advantages:Increases frequency and intensity of uterine
contractionsRelease of prostaglandinsFacilitates decent of presenting partAllows for internal monitoringAbility to assess amniotic fluid
Disadvantages:Disadvantages:Increased risk for infectionPossibility of prolapsed umbilical cord
Artificial Rupture of Membranes
Fig. 20-1d
Amniotomy/Artificial Rupture of Membranes (AROM)Nursing careNursing care
Place disposable pads and towel under-buttock and change frequently
Assess FHR before and after amniotomyDocument: color, clarity, odor
Contraindication:Contraindication:**Procedure should not be performed if head is
not engaged**
Indications for Induction (ACOG, 1999)
Medical ConditionsDiabetes mellitusRenal diseaseChronic HTN
PreeclampsiaPremature
rupture of membranes
ChorioamnionitisPostterm
gestationMild abruptio
placenta IUFDIUGR
Induction/Augmentation of LaborArtificial methods to stimulate uterine
contractions.Induction: Initiation of labor
Medical Elective
Augmentation: Improve quality of contractions
Bishop ScorePre-labor status evaluation scoring system
A predictor for the potential success of induction of labor
A high score indicates the cervix is favorable and vaginal delivery will likely occur
Induction of LaborBishop Score
Score 0 1 2 3Dilation <1cm 1-2cm 2-4cm >4cmEffacement
0-30% 40-50% 60-70% 80%
Fetal Station
-3 -2 -1, 0 +1, +2
Cervical Consistency
Firm Intermediate
Soft
Cervical Position
Posterior Intermediate
Anterior
Cervical RipeningProstaglandin E2 preparations
Prepidil 2.5mg – gelCervidil 10mg – insert on stringCytotec 25mcg - pill
Pitocin (Oxytocin) AdministrationUses of Pitocin:Uses of Pitocin:Induction – initiates uterine contractionsAugmentation – enhances ineffective
contraction pattern
Goal:Goal:A labor pattern with uterine contractions occurring every 2-3 minutes, lasting 40-60 seconds and a return to baseline between contractions
Pitocin (Oxytocin) AdministrationNursing interventions when titrating Pitocin:
Maternal V/SFHR pattern
Baseline Variability Periodic changes
Uterine contraction pattern Frequency Duration Interval
External Version
Fig. 20-3
Internal & External Rotation (version)A procedure performed to change the fetal
presentation Internal
Changing the position of the 2nd twin after delivery of the 1st via vaginal manipulation
ExternalManual rotation of the fetus from breech to
cephalic presentation via external manipulation of the maternal abdomen
External Version: Nursing ManagementPre Procedure:Admission process
Consent for procedure & delivery
V/S & EFMIV accessTocolyticUltrasound
Post Procedure:V/S & EFMPresences of
contraction - LaborRhogam if Rh –S/S abruptio
placentaeRupture of
membranes
Obstetric Forceps
Fig. 20-4 Middle row
Obstetric Forceps (cont’d)
Fig. 20-4 Last row
Birth Assisted with a Vacuum Extractor
Fig. 20-5
EpisiotomyIncision of the perineum just before birth.Indications:
Shoulder dystociaAssisted delivery (forceps/vacuum)OP position
Midline or Mediolateral* Laboring down, perineal massage, pushing in the upright position reduce the incidence of episiotomy.
Cesarean BirthIndicationsRisks
MaternalInfant
Pre-operative care & prepIV hydration/prophylactic antibioticsAnesthesia: epidural/spinalFHRFoley/shave & skin prepTime-out
Skin Incisions for Cesarean Birth
Fig. 20-8
Uterine Incisions for Cesarean Birth
Fig. 20-9
Cesarean Birth: Recovery CareV/S, respirations, O2 sats, ECGLOCAbdominal dressingFundus/LochiaUrinary output/ IV fluidsSensation/movement lower extremitiesPain scaleBonding with infant
Vaginal Delivery After Cesarean Section - VBACIndications:
Previous low transverse uterine incisionNo more than 2 previous C/S
Obtain informed consentNursing Implications
Large bore IV accessContinuous EFM** Increased risk for uterine rupture
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