1. Copyright © 2005 by Elsevier, Inc. All rights reserved. Complications of Labor and Delivery by: Ann Hearn RNC, MSN Spring 2009 Complications of Labor and Delivery by: Ann Hearn RNC, MSN Spring 2009

2. Copyright © 2005 by Elsevier, Inc. All rights reserved. The Powers Complications Uterine Dystocia -defined as difficult labor. –Hypertonic contractions – more frequent but decreased intensity –Hypotonic contractions – decrease in frequency (2-3 UC in 10 min period) Also termed uterine inertia Complications Uterine Dystocia -defined as difficult labor. –Hypertonic contractions – more frequent but decreased intensity –Hypotonic contractions – decrease in frequency (2-3 UC in 10 min period) Also termed uterine inertia

3. Copyright © 2005 by Elsevier, Inc. All rights reserved. Interventions for Uterine Dystocia Hypertonic Uterus: Contractions are painful but ineffective resulting in prolonged latent phase. Nursing Interventions: –Bed rest –Sedation or pain relief –Support/educate –Position changes –Comfort measures: calm environment, music, therapeutic touch, back rub, warm shower, imagery Hypertonic Uterus: Contractions are painful but ineffective resulting in prolonged latent phase. Nursing Interventions: –Bed rest –Sedation or pain relief –Support/educate –Position changes –Comfort measures: calm environment, music, therapeutic touch, back rub, warm shower, imagery

4. Copyright © 2005 by Elsevier, Inc. All rights reserved. Interventions for Uterine Dystocia Hypotonic Uterus: results from overstretched uterine muscle leading to a prolonged active phase. Nursing Interventions: –Amniotomy –Pitocin administration –Emptying bladder –Hydration –Teaching/Support Hypotonic Uterus: results from overstretched uterine muscle leading to a prolonged active phase. Nursing Interventions: –Amniotomy –Pitocin administration –Emptying bladder –Hydration –Teaching/Support

5. Copyright © 2005 by Elsevier, Inc. All rights reserved. Amniotomy/Artificial Rupture of Membranes (AROM) Advantages:Advantages: –Increases frequency and intensity of uterine contractions –Release of prostaglandins –Facilitates decent of presenting part –Allows for internal monitoring –Ability to assess amniotic fluid Disadvantages:Disadvantages: –Increased risk for infection –Possibility of prolapsed umbilical cord Advantages:Advantages: –Increases frequency and intensity of uterine contractions –Release of prostaglandins –Facilitates decent of presenting part –Allows for internal monitoring –Ability to assess amniotic fluid Disadvantages:Disadvantages: –Increased risk for infection –Possibility of prolapsed umbilical cord

6. Copyright © 2005 by Elsevier, Inc. All rights reserved. Artificial Rupture of Membranes Fig. 20-1d

7. Copyright © 2005 by Elsevier, Inc. All rights reserved. Amniotomy/Artificial Rupture of Membranes (AROM) Nursing careNursing care –Place disposable pads and towel under- buttock and change frequently –Assess FHR before and after amniotomy Contraindication:Contraindication: **Procedure should not be performed if head is not engaged** Nursing careNursing care –Place disposable pads and towel under- buttock and change frequently –Assess FHR before and after amniotomy Contraindication:Contraindication: **Procedure should not be performed if head is not engaged**

8. Copyright © 2005 by Elsevier, Inc. All rights reserved. Bishop Score Pre-labor status evaluation scoring system –A predictor for the potential success of induction of labor –A high score indicates the cervix is favorable and vaginal delivery will likely occur Pre-labor status evaluation scoring system –A predictor for the potential success of induction of labor –A high score indicates the cervix is favorable and vaginal delivery will likely occur

9. Copyright © 2005 by Elsevier, Inc. All rights reserved. Induction of Labor Bishop Score Score0123 Dilation<1cm1-2cm2-4cm>4cm Effacement0-30%40-50%60-70%80% Fetal Station -3-2-1, 0+1, +2 Cervical Consistency FirmIntermediateSoft Cervical Position PosteriorIntermediateAnterior

10. Copyright © 2005 by Elsevier, Inc. All rights reserved. Pitocin (Oxytocin) Administration Uses of Pitocin: Induction – initiates uterine contractions Augmentation – enhances ineffective contraction patternGoal: A labor pattern with uterine contractions occurring every 2-3 minutes, lasting 40-60 seconds and a return to baseline between contractions Uses of Pitocin: Induction – initiates uterine contractions Augmentation – enhances ineffective contraction patternGoal: A labor pattern with uterine contractions occurring every 2-3 minutes, lasting 40-60 seconds and a return to baseline between contractions

11. Copyright © 2005 by Elsevier, Inc. All rights reserved. Indications for Induction (ACOG, 1999) –Diabetes mellitus –Renal disease –Preeclampsia –Premature rupture of membranes –History of rapid labor –Diabetes mellitus –Renal disease –Preeclampsia –Premature rupture of membranes –History of rapid labor –Chorioamnionitis –Postterm gestation –Mild abruptio placenta –IUFD –IUGR

12. Copyright © 2005 by Elsevier, Inc. All rights reserved. Pitocin (Oxytocin) Administration Nursing interventions when titrating Pitocin: –maternal V/S –FHR pattern Baseline Variability Periodic changes –Uterine contraction pattern Frequency Duration Interval Nursing interventions when titrating Pitocin: –maternal V/S –FHR pattern Baseline Variability Periodic changes –Uterine contraction pattern Frequency Duration Interval

13. Copyright © 2005 by Elsevier, Inc. All rights reserved. Failure to Progress Prolonged Labor Causes: –Labor dystocia –Malposition –Malpresentation –Macrosomia Interventions: –R/O CPD –Uterine rest –Pitocin augmentation Prolonged Labor Causes: –Labor dystocia –Malposition –Malpresentation –Macrosomia Interventions: –R/O CPD –Uterine rest –Pitocin augmentation

14. Copyright © 2005 by Elsevier, Inc. All rights reserved. Precipitous Labor Labor < 3 hours Complications: –Woman loss of coping ability Lacerations of cervix, vagina, perineum –Fetus Hypoxia Cerebral trauma Pnemothorax Labor < 3 hours Complications: –Woman loss of coping ability Lacerations of cervix, vagina, perineum –Fetus Hypoxia Cerebral trauma Pnemothorax

15. Copyright © 2005 by Elsevier, Inc. All rights reserved. Precipitous Labor Monica, a G1, P0 @ 39.4wks is admitted to L&D with occasional uterine contractions that started soon after her BOW broke an hour ago. She pauses during conversation to breath during contractions and gives a pain rating of 5. Monica states she will probably want an epidural. While performing the admission history/assessment you notice that Monica’s contractions are occurring every 2 minutes and palpate strong. Monica is beginning to demonstrate difficulty with coping during contractions. Monica grunts during her last contraction. What nursing interventions will you provide? Monica, a G1, P0 @ 39.4wks is admitted to L&D with occasional uterine contractions that started soon after her BOW broke an hour ago. She pauses during conversation to breath during contractions and gives a pain rating of 5. Monica states she will probably want an epidural. While performing the admission history/assessment you notice that Monica’s contractions are occurring every 2 minutes and palpate strong. Monica is beginning to demonstrate difficulty with coping during contractions. Monica grunts during her last contraction. What nursing interventions will you provide?

16. Copyright © 2005 by Elsevier, Inc. All rights reserved. The Passenger

17. Copyright © 2005 by Elsevier, Inc. All rights reserved. Malposition of the Fetus Medical Treatments: –Rotation and delivery by: forceps vacuum assisted devise Medical Treatments: –Rotation and delivery by: forceps vacuum assisted devise

18. Copyright © 2005 by Elsevier, Inc. All rights reserved. Internal & External Rotation (version) A procedure performed to change the fetal presentation Internal –Podalic- changing the position of the 2 nd twin after delivery of the 1 st via vaginal manipulation External –Manual rotation of the fetus from breech to cephalic presentation via external manipulation of the maternal abdomen A procedure performed to change the fetal presentation Internal –Podalic- changing the position of the 2 nd twin after delivery of the 1 st via vaginal manipulation External –Manual rotation of the fetus from breech to cephalic presentation via external manipulation of the maternal abdomen

19. Copyright © 2005 by Elsevier, Inc. All rights reserved. External Version Fig. 20-3

20. Copyright © 2005 by Elsevier, Inc. All rights reserved. Three Malpresentations 1.Brow: forehead –C/S delivery 2.Face –Vaginal delivery 3.Breech Frank – buttocks Footling – foot/feet –C/S delivery 1.Brow: forehead –C/S delivery 2.Face –Vaginal delivery 3.Breech Frank – buttocks Footling – foot/feet –C/S delivery

21. Copyright © 2005 by Elsevier, Inc. All rights reserved. Obstetric Forceps Fig. 20-4 Middle row

22. Copyright © 2005 by Elsevier, Inc. All rights reserved. Obstetric Forceps (cont’d) Fig. 20-4 Last row

23. Copyright © 2005 by Elsevier, Inc. All rights reserved. Birth Assisted with a Vacuum Extractor Fig. 20-5

24. Copyright © 2005 by Elsevier, Inc. All rights reserved. Cephalo-pelvic Disproportion CPD Fetus is larger than the pelvic diameter Hallmark symptom is failure of the fetus to descend Causes: –diseases affecting bones (rickets), injury –congenital anomolies, pelvic shape & size Fetus is larger than the pelvic diameter Hallmark symptom is failure of the fetus to descend Causes: –diseases affecting bones (rickets), injury –congenital anomolies, pelvic shape & size

25. Copyright © 2005 by Elsevier, Inc. All rights reserved. Cephalo-pelvic Disproportion CPD Diagnosis –CT scan –Estimated fetal weight per US Trial of labor –Borderline pelvic diameter Support patient –Keep the patient informed of progress –Position changes: sitting squatting, hands & knees may help with descent –Prepare for possible C/S Diagnosis –CT scan –Estimated fetal weight per US Trial of labor –Borderline pelvic diameter Support patient –Keep the patient informed of progress –Position changes: sitting squatting, hands & knees may help with descent –Prepare for possible C/S

26. Copyright © 2005 by Elsevier, Inc. All rights reserved. Skin Incisions for Cesarean Birth Fig. 20-8

27. Copyright © 2005 by Elsevier, Inc. All rights reserved. Uterine Incisions for Cesarean Birth Fig. 20-9

28. Copyright © 2005 by Elsevier, Inc. All rights reserved. Vaginal Delivery After Cesarean Section - VBAC Increased risk for uterine rupture Obtain informed consent Nursing Implications –Large bore IV access –Continuous EFM Increased risk for uterine rupture Obtain informed consent Nursing Implications –Large bore IV access –Continuous EFM

29. Copyright © 2005 by Elsevier, Inc. All rights reserved. Premature Rupture of Membranes - PROM Spontaneous rupture of membranes prior to the onset of labor Associated conditions: –Infection –Previous history of PROM –Hydramnios –Multiple pregnancy –UTI –Trauma Spontaneous rupture of membranes prior to the onset of labor Associated conditions: –Infection –Previous history of PROM –Hydramnios –Multiple pregnancy –UTI –Trauma

30. Copyright © 2005 by Elsevier, Inc. All rights reserved. Premature Rupture of Membranes - PROM Determine time of PROM Verification of PROM: –Visualization –Sterile speculum exam –pH Determine time of PROM Verification of PROM: –Visualization –Sterile speculum exam –pH

31. Copyright © 2005 by Elsevier, Inc. All rights reserved. Premature Rupture of Membranes - PROM Nursing Assessment –Vital signs (temp q 2hr) –Fetal monitoring –Nature of fluid –WBC count Administration of Celestone - betamethasone –PPROM: preterm Nursing Assessment –Vital signs (temp q 2hr) –Fetal monitoring –Nature of fluid –WBC count Administration of Celestone - betamethasone –PPROM: preterm

32. Copyright © 2005 by Elsevier, Inc. All rights reserved. Preterm Labor Defined as: labor that occurs between 20 and 37 weeks gestation. Associated conditions –Multiple gestation –Hydraminos –UTI –Abdominal trauma –Infection –No prenatal care –Low socio-economic status Defined as: labor that occurs between 20 and 37 weeks gestation. Associated conditions –Multiple gestation –Hydraminos –UTI –Abdominal trauma –Infection –No prenatal care –Low socio-economic status

33. Copyright © 2005 by Elsevier, Inc. All rights reserved. Preterm Labor Fetal Fibronectin test –99% accurate predictor of NO preterm birth within 7 days Nursing Implications –Promote rest, hydration, circulation –Monitor FHR and uterine activity –Administer tocolytics as ordered Fetal Fibronectin test –99% accurate predictor of NO preterm birth within 7 days Nursing Implications –Promote rest, hydration, circulation –Monitor FHR and uterine activity –Administer tocolytics as ordered

34. Copyright © 2005 by Elsevier, Inc. All rights reserved. Preterm Labor Tocolytics Medications prescribed to stop preterm labor –Terbutaline – B adrenergic receptor antagonist –Magnesium sulfate – CNS depressant –Ritodrine - not FDA approved for PTL rarely used.Tocolytics Medications prescribed to stop preterm labor –Terbutaline – B adrenergic receptor antagonist –Magnesium sulfate – CNS depressant –Ritodrine - not FDA approved for PTL rarely used.

35. Copyright © 2005 by Elsevier, Inc. All rights reserved. Tocolytic Drugs Smooth muscle relaxants Terbutaline Contraindications: hold and notify HCP if maternal HR > 140bpm Side effects: increase heart rate, feeling of anxiety, headache, increased blood glucose Magnesium Sulfate Contraindications: discontinue for resp. depression, magnesium level >8, administer ca+ gluconate Side Effects: flushing, headache, nausea, lethargy, dizziness, decreased DTR, decreased resp. rate, pulmonary edema Smooth muscle relaxants Terbutaline Contraindications: hold and notify HCP if maternal HR > 140bpm Side effects: increase heart rate, feeling of anxiety, headache, increased blood glucose Magnesium Sulfate Contraindications: discontinue for resp. depression, magnesium level >8, administer ca+ gluconate Side Effects: flushing, headache, nausea, lethargy, dizziness, decreased DTR, decreased resp. rate, pulmonary edema

36. Copyright © 2005 by Elsevier, Inc. All rights reserved. Ruptured Uterus Causes: –Long difficult labor –Injudicious use of Pitocin –Previous C/S Assessment Findings –Fetal bradycardia –Maternal abdominal pain Obstetrical Treatment –Emergency Cesarean Section delivery Causes: –Long difficult labor –Injudicious use of Pitocin –Previous C/S Assessment Findings –Fetal bradycardia –Maternal abdominal pain Obstetrical Treatment –Emergency Cesarean Section delivery

37. Copyright © 2005 by Elsevier, Inc. All rights reserved. Uterine Rupture

38. Copyright © 2005 by Elsevier, Inc. All rights reserved. Prolapsed Umbilical Cord Occurs when the umbilical cord precedes the presenting part. Primary Risk Factor –Fetal head is not engaged or at a high station Vessels carrying blood to & from the fetus are compressed, usually results in fetal distress or possible demise Nursing Interventions –Knee chest position –Administer O2 –Manual lift of fetal head off the cord Occurs when the umbilical cord precedes the presenting part. Primary Risk Factor –Fetal head is not engaged or at a high station Vessels carrying blood to & from the fetus are compressed, usually results in fetal distress or possible demise Nursing Interventions –Knee chest position –Administer O2 –Manual lift of fetal head off the cord

39. Copyright © 2005 by Elsevier, Inc. All rights reserved. Variations of Prolapsed Umbilical Cord Fig. 27-6a

40. Copyright © 2005 by Elsevier, Inc. All rights reserved. Variations of Prolapsed Umbilical Cord (cont’d) Fig. 27-6c

41. Copyright © 2005 by Elsevier, Inc. All rights reserved.

42. Amniotic Fluid Embolism In the presence of a small tear in the amnion and chorion, a small amount of amniotic fluid may leak into the chorionic plate and enter the maternal blood system. Can also occurs at areas of placental separation, cervical tears or during trumultuous labor The more debris (meconium, vernix, lanugo) in the amnionic fluid, the greater the maternal problems caused by possible anaphylactic reaction to fetal antigens In the presence of a small tear in the amnion and chorion, a small amount of amniotic fluid may leak into the chorionic plate and enter the maternal blood system. Can also occurs at areas of placental separation, cervical tears or during trumultuous labor The more debris (meconium, vernix, lanugo) in the amnionic fluid, the greater the maternal problems caused by possible anaphylactic reaction to fetal antigens

43. Copyright © 2005 by Elsevier, Inc. All rights reserved. Amniotic Fluid Embolism Assessment Findings: Sudden onset Respiratory distress (dyspnia) Circulatory collapse (cyanosis) Tachycardia Hypotension Acute hemorrhage Cor Pulmonale Frothy sputum Assessment Findings: Sudden onset Respiratory distress (dyspnia) Circulatory collapse (cyanosis) Tachycardia Hypotension Acute hemorrhage Cor Pulmonale Frothy sputum

44. Copyright © 2005 by Elsevier, Inc. All rights reserved. Amniotic Fluid Embolism Obstetrical Emergency Interventions: –Large bore IV line –Positive pressure oxygen –CPR –Blood transfusion - DIC –Emergency C/S if pregnant Prognosis – 50% of women die with the first hour of symptoms Obstetrical Emergency Interventions: –Large bore IV line –Positive pressure oxygen –CPR –Blood transfusion - DIC –Emergency C/S if pregnant Prognosis – 50% of women die with the first hour of symptoms