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Complicated Labor Patterns Complications of Labor & Delivery
NUR 264
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If was not supposed to be hard work, it would not have been called LABOR.
Anonymous
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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
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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
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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.
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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
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Hypotonic Labor < 2 to 3 contractions in 10 minutes Causes:
Fetal macrosomia Multiple gestation Hydramnios Grand multiparity CPD
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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
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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
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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
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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
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Abnormal Presentations
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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
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Breech Presentations
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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
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Multiple Gestation
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Multiple Gestation
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Cephalopelvic Disproportion
Occurs when fetal head is larger than maternal pelvic diameter Lack of fetal descent in presence of strong contractions Labor usually prolonged
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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
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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
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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
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Shoulder Dystocia McRobert’s Maneuver
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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
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Care of Newborn Care of newborn with macrosomia requires assessment of newborn for: Cephalhematoma Erb's palsy Fractured clavicles Anoxia Cord prolapse
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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
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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
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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
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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
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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
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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
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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
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TABLE 21–3 Placental and Umbilical Cord Variations
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TABLE 21–3 (continued) Placental and Umbilical Cord Variations
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Manual Removal of Placenta
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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
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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
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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
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Birth-related Procedures
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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
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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.
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Risks of Forceps Monitor FHR during procedure Assess newborn for:
Bruising Edema Facial lacerations Cephalhematoma Transient facial paralysis Cerebral hemorrhage
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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
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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.
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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
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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
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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
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Pfannenstiel Classical Incision Incision
increased risk of uterine rupture in subsequent pregnancies and labor.
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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
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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
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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
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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
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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
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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
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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
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NCLEX Question Nursing assessment of a labor patient includes: BP 116/72, P 88, contractions q 2 to 3 minutes, duration seconds, resting tone not returning to baseline, FHR 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
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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
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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
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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
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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
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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
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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
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