1. 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.

2. 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.
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3. Common abbreviations PROM: premature (prelabor) rupture of membranes
PPROM: preterm PROM
PTL: preterm labor
CPD: Cephalopelvic Disproportion

4. 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
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5. 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
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6. 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
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7. 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
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8. 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
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9. 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).
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10. 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)
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11. PPROM
Treatment: antibiotics, corticosteroids (betamethasone), tocolytics
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12. 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.
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13. 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.
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14. 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.
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15. 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.
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16. Dysfunctional Labor Dystocia (cont.)
Causes:
CPD

17. 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.
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18. Dysfunctional Labor Dystocia (cont.)
Causes: Fetal malposition

19. 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

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

21. 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.
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22. 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
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23. What is the difference between induction and augmentation?
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24. 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.
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25. 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.
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26. 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)
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27. Methods of Induction: Pharmacologic
Prostaglandin (PGE2) gel
Nausea, vomiting, diarrhea, fever, hyperstimulation of uterus
Misoprostol (Cytotec)
Has special guidelines that must be followed
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28. 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.
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29. 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
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30. 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.
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31. Assisted Vaginal Delivery
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32. 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.
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33. Vacuum Extraction Application of a cup to fetal head
Withdrawal of air from cap
Traction applied during uterine contractions
Fetal head then delivers
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34. Uterine Complications
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35. 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.
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36. 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
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37. 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.
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38. 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
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39. 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.
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40. 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).
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41. Prolapsed umbilical cord

42. Prolapsed Umbilical Cord

43. 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
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44. Amnioinfusion
Normal saline or lactated Ringer’s solution instilled into amniotic cavity
Corrects oligohydramnios
Reduces thickly stained meconium
Minimizes cord compression
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45. 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
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46. 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).
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47. 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 (p. 297).
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48. 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
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49. 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).
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50. 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
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51. Trial of Labor After Cesarean (TOLAC)
Contraindications
Dystocia
Increased maternal age
Gestational age >40 weeks
Maternal obesity
Preeclampsia
Macrosomia
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52. 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
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53. 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.
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54. Questions?
No notes