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 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 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 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 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 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 nurse-midwife 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 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 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 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 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 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 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 Classical Incision 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? 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? 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? 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. 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? 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