1. Complication o Labor

2. Psychologic Disorders Alterations in thinking, mood or behavior Keep her well oriented and promote optimal functioning in labor. Focus on maintaining safe environment and ensuring fetal and maternal well-being

3. Dystocia r/t dysfunctional contractions Accounts for ~ 50% C/S for primips; <5% C/S for multips Hypertonic: in 1 st phase- poor quality U/Cs, become more frequent, but ineffective and changing dilatation or effacement  prolonged latent phase Tx: sedation, oxytocin, amniotomy Hypotonic: irreg, low amplitude  protracted labor and arrest of dilatation Tx: oxytocin, amniotomy

5. Active Management of Labor Standardized criteria for diagnosis of labor Standardized method of labor management One-to-one nursing care in labor Prenatal education to teach re: this protocol Method: Amniotomy right away VE frequently If change not as expected, oxytocin

6. Precipitous Labor and Birth From beginning of regular contractions to delivery is 3 hours or less Risks: Abruption Cervical and perineal lacerations Fetal head trauma Women with history may be scheduled for induction

7. Post-term Pregnancy > 42 completed weeks Cause of true post-term is unknown; often incorrect dates Maternal Risks: Large baby and associations Psychologic ills Fetal-Neonatal Risks: Placental changes  insufficiencies Oligohydramnios macrosomia  birth trauma, glucose maintenance problems Meconmium stained fluid (aspiration) As pregnancy approached term, fetal well-being studies done

8. Fetal Malposition OP position: Fetus must rotate 135° or occasionally born in OP position If born OP, increased risk of 3 rd or 4 th degree laceration, broken symphysis May use forceps or manual rotation Positioning: knee chest, pelvic rocking

9. Fetal Malpresentation Brow Usually C/S recommended Perinatal morbidity and mortality: Trauma: cerebral and neck compression; damage to trachea and larynx Tx: pelvimetry, oxytocin?, C/S Face Perinatal morbidity and mortality: Risk of prolonged labor, fetal edema, swelling of neck and internal structures, petechiae, ecchymosis Tx: C/S in no progress

10. Fetal Malpresentation Breech Most common malpresentation Frank breech most common Risk of cord prolapse; fetal anomolies 3x higher If vag del: head trauma, fetal entrapment Tx: external version (50-60% success), if vag del: epidural, double set-up

11. Fetal Malpresentation Shoulder Version may be attempted C/S Compound presentation

12. Macrosomia >4500 g Obese 3-4x more likely to have macrosomic baby ↑ risk of perineal lacerations, infection Most significant problem is shoulder dystocia OB emergency  permanent injury of brachial plexus, fx clavicle, asphyxia, neurologic damage Tx: Assessment of adequacy of pelvis Suprapubic pressure Intentional breaking of clavicle ?C/S

13. Multiple Gestation Mother at risk for: Hypertension or preeclampsia Anemia Hydramnios PPROM, IUGR, incompetent cx Malpresentation More physical discomforts

14. Multiple Gestation Tx: U/S to diagnose amnion/chorion, follow growth, observe for twin-twin transfusion Frequent office visits to monitor for problems Likely to deliver by C/S

15. Abruptio Placentae Premature separation of normally implanted placenta from the uterine wall Very high mortality Cause unknown but r/t Maternal hypertension Maternal trauma Cigarettes, cocaine Short umbilical cord, high parity More common in Caucasian and African American than Asian or Latin American

16. Abruptio Placentae

18. http://video.about.com/pregnancy/Pla centa-Abruptio.htm

19. Abruptio Placentae Classification O=asymptomatic, diagnosed after birth I=mild, most common II=mod, both mom and baby show signs of distress III=severe, maternal shock and fetal death likely

20. Abruptio Placentae Types Marginal-blood passes between fetal membranes and uterine wall and escapes vaginally; separation at periphery of placenta Central-separates centrally, blood trapped between placenta and uterine wall. No overt bleeding Complete-massive vaginal bleeding in presence of almost total separation

21. Abruptio Placentae

22. Blood invades myometrial tissue  pain and uterine irritability. May necessitate hysterectomy after delivery secondary to inability to uterus to contract. May lead to coagulation defects

23. Abruptio Placentae Maternal Risks Blood coagulation problems Shock Renal failure (r/t hemorrhage) Possible hysterectomy Fetal-Neonatal Risks If separation ~50%  100% demise Depending upon separation, time before delivery, maturity of baby  neurologic damage

24. Abruptio Placentae Tx Continuous EFM (if baby alive) Develop plan for birth Maintain CV status/tx hypovolemic shock Follow blood coag studies/have blood factors available

25. Placenta Previa Improperly implanted in lower uterine segment Types Low lying: close proximity to os, but doesn’t reach it Marginal: edge of placenta at margin of the os Partial: internal os is partially covered by placenta Total: internal os completely covered

26. Placenta Previa

30. Cause unknown, but associated with Multiparity Increased age Defective development of blood vessels in decidua Defective implantation of the placenta Prior C/S Smoking Large placenta

31. Placenta Previa Tx Continuous EFM Differential diagnosis ☺No vag exam until previa r/o (U/S, other assessments) Care depends on amt bleeding, gestational age, assessment of fetus