Complications of Labor and Birth Chapter 14 Complications of Labor and Birth Review chapter objectives. Copyright © 2012, 2008 by Saunders, an imprint of sevier Inc.

Objectives Define key terms listed. Discuss four factors associated with preterm labor. Describe two major nursing assessments of a woman in preterm labor. Explain why tocolytic agents are used in preterm labor. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Common abbreviations PROM: premature (prelabor) rupture of membranes PPROM: preterm PROM PTL: preterm labor CPD: Cephalopelvic Disproportion

Criteria for Preterm Labor Gestation between 20 to 37 weeks Later preterm is 34 to 36 weeks gestation Documented uterine contractions every 5 to 10 minutes Lasting for at least 30 seconds Persisting more than 1 hour Cervical dilation more than 2.5 cm and 75% effaced Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Preterm Labor Risk Factors History of preterm birth PPROM History of twin or triplet pregnancies <17 years old or >35 years old Smoking Stress Long working hours with long periods of standing Infection Hypertension Diabetes Obesity Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Signs and Symptoms Uterine, menstrual-like cramping Abdominal cramping With or without nausea, vomiting, diarrhea Any vaginal bleeding Change in vaginal discharge Vaginal or pelvic pressure Low back pain Thigh pain Intermittent or persistent Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Stopping Preterm Labor Focus is on stopping contractions before cervix dilates beyond 3 cm Fetal surveillance: fetal heart rate, BPP, NST, and LS ratio to assess lung maturity Tocolytic drugs should not be used if Woman is hemorrhaging—bleeding will increase Fetal distress is noted Tocolytic drugs are not effective if cervix dilated 5 cm or more Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Promotion of Fetal Lung Maturity Goal of tocolytic therapy until steroids can hasten lung maturity Respiratory distress (RDS) can be reduced if steroids are given to mother 24 to 48 hours before birth in fetus less than 34 weeks gestation After delivery, infant is treated with prophylactic surfactant therapy to reduce risk of developing RDS Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Premature Rupture of Membranes (PROM) Spontaneous rupture of amniotic sac more than 1 hour before onset of true labor (PROM) If rupture occurs before 37 weeks gestation, it is called preterm premature rupture of membranes (PPROM) See Skill 14-1 (p. 284). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

PROM Infection for mother and fetus Compression of umbilical cord Complications of PROM Risk factor/Treatment Infection for mother and fetus Compression of umbilical cord Prolapse of umbilical cord Risk factor: Infection Treatment: Expectant management Induction of labor: Oxytocin (Pitocin) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

PPROM Treatment: antibiotics, corticosteroids (betamethasone), tocolytics Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Test your knowledge Respiratory distress (RDS) in an infant born at less than 34 weeks’ gestation can be reduced if steroids are given to the: Mother 24 to 48 hours before birth in fetus Infant with 24 to 48 hours after birth Mother within 2 to 4 hours before birth Infant 2 to 4 hours after birth Answer: A. Steroids are given to hasten fetal lung maturity. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Dystocia Known as dysfunctional labor; difficult or abnormal labor Primarily results from Powers Passageway (pelvis) Passenger Psyche Refer to Table 14-3 (p. 285). Dystocia is suspected when rate of cervical dilation or fetal descent is not progressing normally or contractions are ineffective. Associated problems such as maternal dehydration, exhaustion, increased risk of infection, and fetal distress are contributing factors to dystocia. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Powers Abnormal uterine contractions Hypotonic dysfunction Prevent normal progress of dilation, effacement, and fetal descent Hypotonic dysfunction Contractions weaken, not strong enough to dilate cervix beyond 4 cm Hypertonic uterine dysfunction Contractions of poor quality, pain is out of proportion to intensity, dilation and effacement affected See Table 14-4 (p. 286). Common causes of hypotonic contractions are ______________. Answer: fetopelvic disproportion, fetal malposition, overstretching of uterus due to large newborn, multifetal gestation, or excessive maternal anxiety. Management of hypertonic uterine dysfunction includes_____________. Answer: rest, analgesia to reduce pain and promote sleep, IV fluids to maintain hydration and electrolytes. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Passageway Abnormal pelvic size or shape May be a result of Congenital malformation Rickets Maternal malnutrition Tumors Previous pelvic fractures What are some of the potential problems that can occur due to maternal pelvic shape and size? Answer: fetal descent could stop; uterine rupture. The most common cause of pelvic dystocia is _________. Answer: midplane contractures. The most common minor obstruction is related to ______________, which can be resolved by __________. Answer: bladder distention; catheterization to drain the urinary bladder. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Dysfunctional Labor Dystocia (cont.) Causes: CPD

Passenger Cephalopelvic disproportion (CPD) Presenting part too large for maternal pelvis Abnormal fetal presentation Fetus not in vertex position Breech, face-brow, persistent occiput posterior External version Can help reduce the need for cesarean What conditions are associated with CPD? Answer: excessive fetal size due to diabetes mellitus, multiparity, and genetics. Maternal complications related to CPD are ____________. Answer: exhaustion, hemorrhage, and infection. Fetal complications related to CPD are_____________. Answer: birth trauma, anoxia. Breech presentations are often associated with preterm birth, multiple gestation, congenital anomalies, placenta previa, and multiparity. Review Figure 14-2 (p. 287), various breech presentations. What could the presence of meconium in the amniotic fluid mean in a breech birth? Answer: may be a result of pressure being applied to abdominal cavity and buttocks of the fetus. Why should the fetal head be delivered as quickly as possible in a breech birth? Answer: to avoid hypoxia. Risks from external version include___________. Answer: prolapsed umbilical cord and abruptio placentae. Uterine malformations, previous cesarean birth, placenta previa, and uteroplacental insufficiency are __________ to breech delivery. Answer: contraindications. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Dysfunctional Labor Dystocia (cont.) Causes: Fetal malposition

Shoulder dystocia OBSTRETIC EMERGENCY Fetal head delivers, but the shoulders become stuck in the bony pelvis, preventing delivery of the body. May lead to fetal death, permanent brain damage, brachial plexus injury, and/or fractures Most common in macrosomia and maternal diabetes

Shoulder dystocia Classical sign: “turtle sign” Treatment: McRobert’s maneuver Suprapubic pressure

Psyche Epinephrine is released in response to stress Examples Inhibits contractions and diverts blood from uterus Examples Perceived fears of pain Nonsupport Embarrassment Violation of religious rituals Help the woman to relax as much as possible. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Induction of Labor and Augmentation Measures taken to initiate uterine contractions before they spontaneously begin Augmentation Use of an oxytocic drug after spontaneous but ineffective labor has begun Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

What is the difference between induction and augmentation? Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Reasons for Induction Maternal indications Fetal indications Infection (chorioamnionitis) PROM Worsening medical disorders (e.g., gestational hypertension) Fetal indications Intrauterine growth restriction Postterm newborn Fetal demise Induction of labor is contraindicated if mother has____________. Answer: active genital herpes, CPD, cord prolapse, placenta previa, or vertical incision of uterus from previous cesarean birth. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Methods of Induction CAM therapy Cervical ripening Primrose oil, black haw, black cohosh, red raspberry leaves Sexual intercourse Acupuncture and TENS Cervical ripening Evaluated using Bishop’s score 6 or higher predicts higher success rate See Table 14-5: Bishop Scale (p. 290). Sexual intercourse is believed to help with labor due to ______________. Answer: the release of oxytocin resulting from breast stimulation, release of natural prostaglandin from semen, and female orgasm. Acupuncture and TENS may induce labor by ______________. Answer: stimulating the release of natural prostaglandins and oxytocin. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Methods of Induction: Nonpharmacologic Stripping of membranes Digital separation of amniotic membranes Amniotomy Artificial rupture of membranes Mechanical dilators Inserted into cervix to gradually increase dilation Can be painful, replaced by Hygroscopic dilators Laminaria (seaweed) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Methods of Induction: Pharmacologic Prostaglandin (PGE2) gel Nausea, vomiting, diarrhea, fever, hyperstimulation of uterus Misoprostol (Cytotec) Has special guidelines that must be followed Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Oxytocin Induction and Augmentation Helps induce the labor process or augment labor that is progressing slowly due to ineffective uterine contractions Has antidiuretic effect Common side effects include Uterine hyperstimulation Reduced fetal oxygenation Uterine hyperstimulation may lead to____________. Answer: uteroplacental insufficiency, fetal compromise, uterine rupture, and very rapid labor with potential uterine or cervical lacerations. When should the nurse stop the oxytocin infusion? Answer: if uterine hyperstimulation or nonreassuring fetal heart rate occurs. What position is best for the mother? Answer: side-lying increases placental perfusion. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Oxytocin and Nursing Assessment Uterine activity Cervical dilation Maternal-fetal response Intake and output To assess for water intoxication Discontinue administration immediately if Uterine hyperstimulation Nonreassuring fetal heart rate Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Episiotomy Surgical incision made into perineum to permit easier passage of fetus Shortens second stage of labor Relieves compression of fetal head Facilitates breech and forceps birth Perineum can tear; 1st- to 4th-degree lacerations. Measures to enhance perineal stretching include warm compresses, warm oil, and perineal massage. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Assisted Vaginal Delivery Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Forceps-Assisted Birth Criteria Membranes ruptured Cervix fully dilated Fetal head below ischial spines or on perineum Bladder empty Analgesia adequate Review Box 14-1 (p. 292). Newborn can have bruising and edema of scalp, potential cephalohematoma, and intracranial hemorrhage. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Vacuum Extraction Application of a cup to fetal head Withdrawal of air from cap Traction applied during uterine contractions Fetal head then delivers Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Uterine Complications Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postterm Labor and Birth Birth beyond 42 weeks gestation Risks to mother Dysfunctional contractions Vaginal canal lacerations Infection Risks to fetus Birth trauma, Meconium aspiration CPD Hypoxia Tests for fetal well-being include_________. Answer: nonstress test, biophysical profile, assessment of fetal movement, fetal breathing, amniotic fluid volume. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Precipitate Labor Labor completed in less than 3 hours from time of first true labor to birth of fetus Can cause fetal hypoxia Intervillous blood flow may be impaired because uterus cannot relax enough Cervical, vaginal, or perineal lacerations can occur Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Uterine Rupture Rare Occurs most often during labor and delivery Associated with previous cesarean Rupture occurs at site of previous surgical scar Aggressive or poorly supervised induction of labor Fetopelvic disproportion The major complications from uterine rupture are___________. Answer: maternal hemorrhage and fetal demise. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Hydramnios Excessive amount of amniotic fluid, greater than 2 L Congenital anomalies, especially of fetal GI tract Uterus overdistends Removal of excess amniotic fluid may cause abruptio placentae or prolapsed cord Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Oligohydramnios Decreased amount of amniotic fluid Associated with Fetal renal anomalies Intrauterine growth restriction Fetus at risk for impaired musculoskeletal development Why is the fetus at risk for impaired musculoskeletal development with oligohydramnios? Answer: inability to move freely in uterus; tangling of long cord around extremity; cord compression or kinking. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Prolapse of the Umbilical Cord Cord precedes fetal presenting part Contributing factors ROM before fetal head engaged Small fetus Breech presentation Transverse lie Hydramnios Unusually long cord Multifetal pregnancy Review nursing actions that should be taken should prolapsed cord occur. See Figure 14-9 (p. 294). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Prolapsed umbilical cord

Prolapsed Umbilical Cord

Nursing Interventions in Prolapsed Cord Place woman’s hips higher than head by Knee-chest position Trendelenburg position Side-lying position with hips elevated on pillows With sterile gloved hand, push fetal presenting part away from cord Start oxygen 8 to 10 L/min by mask Closely monitor FHR by EFM Prepare for rapid delivery Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Amnioinfusion Normal saline or lactated Ringer’s solution instilled into amniotic cavity Corrects oligohydramnios Reduces thickly stained meconium Minimizes cord compression Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Multifetal Pregnancy Two or more fetuses in utero Preterm labor can occur due to over-distended uterus Increased risk of anemia, hypertension, and hemorrhage Twin-to-twin transfusion syndrome Death of one twin in utero while other survives; increases risk of DIC in mother Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Indications for Cesarean Birth Previous cesarean birth Failed trial of labor (failure to progress) Fetal distress Uncontrolled bleeding Fetopelvic disproportion or malpresentation Prolapsed cord Active herpes simplex viral infection Postmaturity See Box 14-2 (p. 296). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Surgical Techniques Skin incisions Uterine incisions Transverse (Pfannenstiel’s) Lowest part of abdomen Does not allow for extension of incision Vertical Between naval and symphysis pubis Quicker and preferred in fetal distress Uterine incisions Upper or lower segment Upper has higher risk of rupture with future pregnancy See Figure 14-11 (p. 297). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Complications and Risks Maternal Aspiration Pulmonary embolism Hemorrhage Urinary tract infection Bowel or bladder injury Infection Thrombophlebitis Anesthesia Fetal Preterm (if gestational age not correctly calculated) Fetal injuries Respiratory problems Delayed absorption of lung fluids Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Nursing Care: Preoperative Care NPO to reduce risk of aspiration IV access started and confirmed Witness informed consent Cleanse abdomen; clip hair if the hair may interfere with closing and suturing of wound Indwelling Foley catheter is placed Administer medications as ordered Review laboratory results Provide teaching Teaching should include coughing, deep breathing, and ambulation. See Box 14-3 (p. 299). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Newborn Care Pediatrician and newborn nursery nurse typically present in delivery room Heated crib and resuscitation equipment Infant placed in radiant warmer; skin temperature probe applied Apgar scoring Identification banding Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Trial of Labor After Cesarean (TOLAC) Contraindications Dystocia Increased maternal age Gestational age >40 weeks Maternal obesity Preeclampsia Macrosomia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Vaginal Birth After Cesarean (VBAC) Intrapartum care essentially same as for any woman in labor Close observation of fetal status and uterine contractions Use of cervical ripening not recommended Augmentation with oxytocin can be done with close monitoring Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Test your knowledge …… Placing the woman’s hips higher than her head using knee-chest position, Trendelenburg position, or side-lying position with hips elevated on pillows is done in which situation? Amnioinfusion Breech presentation Prolapsed umbilical cord Precipitate delivery Answer: C. These interventions can help minimize cord compression and increase fetal oxygenation until help arrives. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Questions? No notes