1. Labor and Birth Complications
Chapter 32
Labor and Birth Complications
Copyright © 2016 by Elsevier Inc. All rights reserved.

2. Learning Objectives
Differentiate between preterm birth and low birth weight.
Describe the criteria for very preterm, early preterm, late preterm, and the implications of each.
Discuss major risk factors associated with preterm labor.
Analyze current interventions to prevent spontaneous preterm birth.

3. Learning Objectives (Cont.)
Discuss the use of tocolytics and antenatal glucocorticoids for management of preterm labor.
Design a nursing care plan for women with preterm premature rupture of membranes (preterm PROM).
Explain the care of a woman with postterm pregnancy.
Explain the challenge of caring for obese women during labor and birth.

4. Learning Objectives (Cont.)
Summarize the nursing care for a trial of labor, the induction and augmentation of labor, forceps- and vacuum-assisted birth, cesarean birth, and vaginal birth after a cesarean birth (VBAC).
Discuss obstetric emergencies and their appropriate management.

5. Preterm Labor and Birth
Preterm labor (PTL): cervical changes and uterine contractions occurring at 20 to 37 weeks of pregnancy
Preterm birth: birth that occurs before the completion of 37 weeks (<37 0/7 weeks of gestation)

6. Preterm Labor and Birth (Cont.)
Preterm birth versus low birth weight
Preterm birth or prematurity: length of gestation regardless of birth weight
More dangerous than birth weight alone because less time in the uterus correlates with immaturity of body systems
Low birth weight: ≤2500 grams at birth
Many potential causes, including preterm
Intrauterine growth restriction (IUGR)

7. Preterm Labor and Birth (Cont.)
Spontaneous versus indicated preterm birth
Spontaneous: 75% of preterm births
Indicated: 25% of preterm births
Causes of spontaneous preterm labor and birth
Multifactorial
Infection is the only definitive factor
Placental causes

8. Preterm Labor and Birth (Cont.)
Predicting spontaneous preterm labor and birth
Risk factors
Cervical length
Not predictive of PTL or birth
But cervical length >30 mm unlikely to give birth prematurely
Fetal Fibronectin (fFN)Test
fFN is a glycoprotein “glue” found in plasma and produced during fetal life.

9. PTL Care Management Assessment Interventions Lifestyle modifications
Patient teaching
Interventions
Prevention
Early recognition and diagnosis
Lifestyle modifications
Activity restriction
Restriction of sexual activity
Home care

10. PTL Care Management (Cont.)
Suppression of uterine activity
Tocolytic medications
Promotion of fetal lung maturity
Antenatal glucocorticoids: significantly reduce the incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death in neonates
Management of inevitable preterm birth
Fetal and early neonatal loss

11. Premature Rupture of Membranes (PROM)
PROM: Spontaneous rupture of amniotic sac and leakage of fluid prior to the onset of labor at any gestational age
PPROM: membranes rupture before 37 0/7 weeks of gestation
Responsible for 10% of all preterm births
Often preceded by infection
Chorioamnionitis

12. PROM and PPROM Care Management
Determined individually for each woman
Full-term birth is the best option.
PPROM <32 weeks is managed expectantly and conservatively.
Vigilance for signs of infections
Fetal assessment
Antenatal glucocorticoids

13. Chorioamnionitis Bacterial infection of the amniotic cavity
Major cause of complications for mothers and newborns at any gestational age
Diagnosed by the clinical findings of maternal fever, maternal and fetal tachycardia, uterine tenderness, and foul odor of amniotic fluid
Neonatal risks
Treatment

14. Postterm Pregnancy, Labor, and Birth
Postterm pregnancy (postdates) pregnancy ≥42 weeks of gestation
Maternal risks
Dysfunctional labor and birth canal trauma
Labor and birth interventions more likely
Woman may experience fatigue and psychologic reactions as estimated date of birth passes.

15. Postterm Pregnancy, Labor, and Birth (Cont.)
Fetal risks
Abnormal fetal growth (macrosomia)
Prolonged labor
Shoulder dystocia
Birth trauma
Compromising effects on fetus of “aging” placenta
Postmaturity syndrome

16. Postterm Pregnancy, Labor, and Birth (Cont.)
Care management
Controversial
Perinatal morbidity and mortality increase greatly after 42 weeks of gestation.
More frequent fetal assessment, testing

17. Case Study
Your client is a G2 P1001 at 42 weeks gestation. Her biophysical profile (BPP) exam was 4/10.
What does this mean about the health of her fetus?
Given her gestational age, what are some of the potential causes of this condition?
To review the BPP, see Chapter 26:
BPP scoring and management are detailed in Tables 26-2 and 26-3.
The BPP is used frequently in the late second and the third trimester for antepartum fetal testing because it is a reliable predictor of fetal well-being. A BPP of 8 or 10 with a normal AFV is considered normal. Advantages of the test include excellent sensitivity and a low false-negative rate (Miller et al., 2013). One limitation of the test is that, if the fetus is in a quiet sleep state, the BPP can require a long period of observation. Also, unless the ultrasound examination is videotaped, it cannot be reviewed (Greenberg et al., 2012).
Categories of risk include biophysical, psychosocial, sociodemographic, and environmental (Box 26-1). Risk factors are interrelated and cumulative in their effects.
Biophysical risks include factors that originate within the mother or fetus and affect the development or functioning of either one or both. Examples include genetic disorders, nutritional and general health status, and medical or obstetric-related illnesses. Box 26-2 lists common risk factors for several pregnancy-related problems.
See Chapter 32, Postterm Pregnancy, Labor and Birth; Maternal and Fetal Risks; Care Management
Maternal risks are often related to dysfunctional labor, such as increased risk for perineal injury related to fetal macrosomia. Risk for hemorrhage and infection is higher. Interventions such as induction of labor with prostaglandins or oxytocin, forceps- or vacuum-assisted birth, and cesarean birth are more likely to be necessary. Each of these interventions, of course, carries its own set of risks. The woman also may experience fatigue, physical discomfort, and psychologic reactions such as depression, frustration, and feelings of inadequacy as she passes her estimated date of birth. Relationships with close friends and family members may become strained, and the woman’s negative feelings about herself may be projected as feelings of resentment toward the fetus (Gilbert, 2011; Rampersad & Macones, 2012).
Another complication associated with postterm pregnancy is abnormal fetal growth. Although the risk of having a small for gestational age infant is increased, only 10% to 20% of postterm fetuses are undernourished. Macrosomia (birth weight more than 4000 g) occurs far more often. Macrosomia occurs when the placenta continues to provide adequate nutrients to support fetal growth after 40 weeks of gestation. Macrosomic infants have an increased risk for operative delivery and shoulder dystocia leading to fetal injury (Rampersad & Macones, 2012).
Other fetal risks associated with postterm gestation are related to the intrauterine environment. After 43 to 44 weeks of gestation, the placenta begins to age. Enlarging areas of infarction and increased deposition of calcium and fibrin in its tissue decrease the placenta’s reserve and may affect its ability to oxygenate the fetus. Decreased amniotic fluid (less than 400 ml), oligohydramnios, is the complication most frequently associated with postterm pregnancy. Because of the decreased amount of amniotic fluid, there is a potential for cord compression and resulting hypoxemia (Gilbert, 2011). Other potential complications include meconium-stained amniotic fluid and increased chance of meconium aspiration (Rampersad & Macones, 2012).
Postmaturity syndrome occurs in 10% to 20% of neonates born following postterm pregnancies. Postmaturity syndrome is characterized by dry, cracked, peeling skin; long nails; meconium staining of skin, nails, and umbilical cord; and perhaps loss of subcutaneous fat and muscle mass (Gilbert, 2011; Rampersad & Macones, 2012).

18. Case Study (Cont.)
Her cervical exam reveals cervix is closed/long/ -3/firm/posterior
What is her Bishop’s score?
Given this score, what type of induction orders might the nurse anticipate?
See Table 32-3: Her Bishop’s score is 0. All five assessment categories receive a zero.
The nurse would anticipate cervical ripening orders (Prostaglandin gel, Cervidil, cervical dilators, etc.).
See Chapter 32: Induction of Labor; Cervical Ripening Methods; Augmentation of Labor.

19. Case Study (Cont.)
What potential newborn complications might the nurse expect at birth?
Describe some typical features of the postdates newborn.
From Chapter 32:
During labor, the fetus of a woman with a postterm pregnancy should be continuously monitored electronically for a more accurate assessment of the FHR and pattern. Inadequate fluid volume can lead to compression of the umbilical cord, which results in fetal hypoxia that is reflected in variable or prolonged deceleration patterns. If oligohydramnios is present, an amnioinfusion may be performed to restore amniotic fluid volume to maintain a cushioning of the cord. See Chapter 18 for additional information on amnioinfusion. 
From Chapter 34: Features of Postmature Infants:
A pregnancy that is prolonged beyond 42 weeks is a postterm pregnancy, and the infant who is born is called postterm or postmature. Postmaturity can be associated with placental insufficiency, resulting in a fetus that has a wasted appearance (dysmaturity) at birth because of loss of subcutaneous fat and muscle mass. However, not all postmature infants show signs of dysmaturity; some will continue to grow in utero and will be large at birth. Most postmature infants are oversized but otherwise normal, with advanced development and bone age. A postmature infant will have some, but not necessarily all, of the following physical characteristics (McGrath & Hardy, 2011):
Generally a normal skull, but the reduced dimensions of the rest of the body in the presence of dysmaturity make the skull look inordinately large
Dry, cracked (desquamating), parchment-like skin at birth
Firm nails extending beyond the fingertips
Profuse scalp hair
Depleted subcutaneous fat layers, leaving the skin loose and giving the infant an “old person” appearance
Long and thin body
Absent vernix
Can have meconium staining (golden yellow to green) of skin, nails, and cord, indicative of a hypoxic episode in utero or a perinatal infection such as listeriosis
Can have an alert, wide-eyed appearance symptomatic of chronic intrauterine hypoxia
The perinatal mortality rate is significantly higher in the postmature fetus and neonate. One reason for this is that during labor and birth the increased oxygen demands of the postmature fetus are not fully met. Insufficient gas exchange in the postmature placenta also increases the likelihood of intrauterine hypoxia, which can result in the passage of meconium in utero, thereby increasing the risk for meconium aspiration syndrome (MAS).
Parents may be concerned about the appearance of the postmature infant. Nurses can help them understand reasons for the dry, peeling, skin and other characteristics of postmaturity. Initial bathing should be done with a mild soap. It can be helpful to moisturize the skin with a petrolatum-based ointment. Nurses need to be alert to common problems associated with postmaturity such as meconium aspiration, fetal distress, macrosomia, and birth injury (De los Santos-Garate et al., 2011).

20. Dysfunctional Labor (Dystocia): Overview
Long, difficult, or abnormal labor
Most common indication for c-birth
Five factors affect labor
The powers
The passage
The passenger
Maternal position
Psychologic responses

21. Dysfunctional Labor (Dystocia): Causes
Abnormal uterine activity
Hypertonic uterine dysfunction
Therapeutic rest
Hypotonic uterine dysfunction
Initially makes normal progress into the active phase of first-stage labor but then the contractions become weak and inefficient or stop altogether

22. Dysfunctional Labor (Dystocia): Causes (Cont.)
Secondary powers
Problems with bearing-down efforts
Abnormal labor patterns
Friedman’s classification of “normal” labor patterns
Updated, evidence-based awareness of “normal” labor
Precipitous labor
Labor that lasts less than 3 hours from the onset of contractions to the time of birth

23. Dysfunctional Labor (Dystocia): Causes (Cont.)
Alterations in pelvic structure
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 that of bony pelvis

24. Dysfunctional Labor (Dystocia): Causes (Cont.)
Fetal causes
Anomalies
Cephalopelvic disproportion (CPD), also called fetopelvic disproportion (FPD)
Malposition
Malpresentation
Multifetal pregnancy

25. Dysfunctional Labor (Dystocia): Causes (Cont.)
Position of the woman
Maternal position alters relationship between uterine contractions, fetus, and mother’s pelvis
Psychologic responses
Hormones and neurotransmitters released in response to stress can cause dystocia
Sources of stress and anxiety vary

26. Obesity Serious problem in affluent nations BMI of 30 kg/m2 or greater
BMI of 40 kg/m2 or greater extremely obese
Complications
Venous thromboembolism
Cesarean birth

27. Obstetric Procedures: Version
External cephalic version (ECV)
An attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth
Ultrasound scanning used during procedure
NST and informed consent before procedure
Contraindications to ECV
Internal version
Rarely used; safety questionable
Used most often in twin gestations to deliver the second fetus

28. Obstetric Procedures: Version (Cont.)

29. Obstetric Procedures: Induction of Labor
The chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about birth
Labor may be induced either electively or for indicated reasons.

30. Obstetric Procedures: Induction of Labor (Cont.)
Elective induction of labor
Labor is initiated without a medical indication.
Many are for the convenience of the woman or her primary health care provider.
Risks:
Increased rates of cesarean birth
Increased neonatal morbidity
Increased cost
Elective induction of labor should not be initiated until the woman reaches 39 completed weeks of gestation.

31. Obstetric Procedures: Induction of Labor (Cont.)
Bishop’s score
A rating system used to evaluate inducibility or cervical ripeness

32. Obstetric Procedures: Induction of Labor (Cont.)
Cervical ripening methods
Chemical agents
Mechanical and physical methods
Alternative methods
Amniotomy
Oxytocin
Hormone normally produced by the posterior pituitary gland, which stimulates uterine contractions and aids in milk let-down
Synthetic oxytocin (Pitocin) may be used either to induce labor or to augment labor that is progressing slowly because of inadequate uterine contractions.

33. Obstetric Procedures: Augmentation of Labor
Stimulation of uterine contractions after labor has started spontaneously and progress is unsatisfactory
Common augmentation methods include oxytocin infusion and amniotomy.
Active management

34. Obstetric Procedures: Operative Vaginal Birth
Operative vaginal births are performed using either forceps or a vacuum extractor
Forceps-assisted birth

35. Obstetric Procedures: Operative Vaginal Birth (Cont.)
Operative vaginal births are performed using either forceps or a vacuum extractor
Vacuum-assisted birth

36. Obstetric Procedures: Cesarean Birth Overview
Birth of a fetus through a transabdominal incision of the uterus to preserve the well-being of the mother and her fetus
Cesarean birth rate in the United States has been over 32% since the early 2000s
VBAC = Vaginal birth after cesarean
TOLAC = Trial of labor after cesarean

37. Obstetric Procedures: Cesarean Birth (Cont.)
Elective cesarean birth
Scheduled cesarean birth
Unplanned cesarean birth
Forced cesarean birth

38. Obstetric Procedures: Cesarean Birth (Cont.)
Surgical techniques

39. Obstetric Procedures: Cesarean Birth (Cont.)
Complications and risks
Anesthesia
Prenatal preparation
Preoperative care

40. Obstetric Procedures: Cesarean Birth (Cont.)
Intraoperative care

41. Obstetric Procedures: Cesarean Birth (Cont.)
Immediate postoperative care
Postoperative postpartum care
Nursing interventions
Trial of labor
Vaginal birth after cesarean

42. Obstetric Emergencies
Meconium-stained amniotic fluid
Indicates fetus has passed stool prior to birth
Dark green
Possible causes
Normal physiologic function of maturity
Breech presentation
Hypoxia-induced peristalsis
Umbilical cord compression

43. Obstetric Emergencies (Cont.)
Shoulder dystocia
Head is born, but anterior shoulder cannot pass under pubic arch
Newborn more likely to experience birth injuries related to asphyxia, brachial plexus damage, and fracture
Mother’s primary risk stems from excessive blood loss from uterine atony or rupture, lacerations, extension of episiotomy, or endometritis.

44. Obstetric Emergencies (Cont.)

45. Obstetric Emergencies (Cont.)
Prolapsed umbilical cord
Occurs when cord lies below the presenting part of the fetus
Contributing factors include:
Long cord (longer than 100 cm)
Malpresentation (breech)
Transverse lie
Unengaged presenting part

46. Obstetric Emergencies (Cont.)

47. Obstetric Emergencies (Cont.)
Rupture of the uterus
Rare, serious obstetric injury; occurs in 1 in 2000 births
Most frequent causes of uterine rupture during:
Separation of scar of a previous classic cesarean birth
Uterine trauma (e.g., accidents, surgery)
Congenital uterine anomaly

48. Obstetric Emergencies (Cont.)
Rupture of the uterus (Cont.)
During labor and birth
Intense spontaneous uterine contractions
Labor stimulation (e.g., oxytocin, prostaglandin)
Overdistended uterus (e.g., multifetal gestation)
Malpresentation, external or internal version
Difficult forceps-assisted birth
Occurs more in multigravidas than primigravidas

49. Obstetric Emergencies (Cont.)
Amniotic fluid embolus (AFE), also called anaphylactoid syndrome of pregnancy (ASP)
Amniotic fluid containing particles of debris (e.g., vernix, hair, skin cells, or meconium) enters the maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse

50. Key Points
Preterm birth is any birth that occurs between 20 0/7 and 36 6/7 weeks of gestation.
Preterm labor is generally diagnosed clinically as regular contractions along with a change in cervical effacement or dilation or both or presentation with regular uterine contractions and cervical dilation of at least 2 cm. The incidence of preterm birth varies considerably by race. In the United States, non-Hispanic black women have the highest rate of preterm birth.
The cause of preterm labor is unknown and is assumed to be multifactorial; therefore, it is not possible to predict with certainty which women will experience preterm labor and birth.

51. Key Points (Cont.)
Because the onset of preterm labor is often insidious and can be mistaken for normal discomforts of pregnancy, nurses should teach all pregnant women how to detect the early symptoms of preterm labor and to call their primary health care provider when symptoms occur.
The best reason to use tocolytic therapy is to achieve sufficient time to administer glucocorticoids in an effort to accelerate fetal lung maturity. Additionally, time is allowed for transport of the woman prior to birth to a center equipped to care for preterm infants.

52. Key Points (Cont.)
If fetal or early neonatal death is expected, the parents and members of the health care team need to discuss the situation before the birth and decide on a management plan that is acceptable to everyone.
Vigilance for signs of infection is an essential component of the care management for women with preterm PROM.
Dysfunctional labor results from differences in the normal relationships among any of the five factors affecting labor and is characterized by differences in the pattern of progress in labor.

53. Key Points (Cont.)
Obese women are at risk for several pregnancy complications, including cesarean birth. Even routine procedures require more time and effort to accomplish when the client is obese.
Uterine contractility is increased by the effects of oxytocin and prostaglandin and is decreased by tocolytic agents.
Labor should not be induced electively until the woman has reached at least 39 weeks of gestation.
Cervical ripening using chemical or mechanical measures can increase the success of labor induction.

54. Key Points (Cont.)
Expectant parents benefit from learning about operative obstetrics (e.g., forceps-assisted, vacuum-assisted, or cesarean birth) during the prenatal period.
The basic purpose of cesarean birth is to preserve the well-being of the mother and her fetus.
Unless contraindicated, vaginal birth is possible after a previous cesarean birth.

55. Key Points (Cont.)
Labor management that emphasizes one-to-one support of the laboring woman by another woman (e.g., doula, nurse, nurse-midwife) can reduce the rate of cesarean birth and increase the VBAC rate.
Obstetric emergencies (e.g., meconium-stained amniotic fluid, shoulder dystocia, prolapsed cord, rupture of the uterus, and amniotic fluid embolism) occur rarely but require immediate intervention to preserve the health or life of the mother and fetus or newborn.

56. Question
A pregnant woman arrives on the labor and delivery unit and informs the nurse that her infant is in a breech presentation. This presentation is associated with an increased risk for childhood handicap; therefore this baby will likely be delivered by cesarean birth. The client may wish to undergo an external cephalic version (ECV) in an attempt to manually reposition the baby into a vertex presentation. A number of interventions may be implemented to support this procedure and increase the likelihood of success. Studies have shown which intervention to be the most successful?
Tocolysis
Nitrous oxide
Spinal or epidural analgesia
Amnioinfusion
ANS: A
Feedback
A Correct: Tocolysis improved the rate of ECV success. Fetal bradycardia was less frequent and there were fewer cesarean births. One small study also showed vibroacoustic stimulation to be very effective at facilitating ECV.
B Incorrect: Nitrous oxide administration decreased the success rate of ECV and was likely to result in headaches and hypotension.
C Incorrect: The results of either spinal or epidural analgesia prior to ECV were equivocal. Two trials showed a benefit for ECV success with the use of epidurals, and three other trials indicated no improvement whatsoever.
D Incorrect: No trials for amnioinfusion have been identified. Increasing amniotic fluid volume increases the risk for infection and ruptured membranes.