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

32. Other Placental Problems Note re: infarcts and calcifications As placenta matures  calcifications and infarcts Calcification more often r/t age and diabetes Infarcts more often r/t severe preeclampsia and smoking

33. Prolapsed Cord Umbilical cord precedes presenting part May be visible or occult More common with Abnormal lie Low birth weight > previous births Amniotomy Long cord

37. 37 Prolapsed Cord Key interventions Relieve pressure on cord Trendelberg or knee chest position Oxygen to increase maternal oxygen saturation Pressure on the presenting part Call for help, but do not leave mother Expedite delivery

39. Prolapsed Cord Maternal Risk No direct risk Fetal-Neonatal Risk Cord compression  ↓ O2  possible death or neurologic compromise Tx Prevention! If palpated, keep pressure off cord ☺ When ROM occurs, listen to FHTs for full minute; if decel heard, do vag exam to r/o cord prolapse

40. Umbilical Cord Abnormalities 2 vessel cord: associated with abnormalities, esp kidney Check for 3 vessels at time of birth (2 arteries 1 vein)

41. Amniotic Fluid-Related Complications Embolism: bolus of amniotic fluid enters maternal circulation then lungs. OB emergency! High mortality.

42. Amniotic Fluid-Related Complications Hydramnios: >2000mL of fluid Cause unknown but associated with congenital abnormalities (swallowing/voiding problems); also diabetes, Rh sensitization, infections such as CMV, Rubella, syphilis, toxoplasmosis, herpes If severe (>3000mL) may experience severe edema, hypotension (from vena cava compression) and pain Tx Supportive Corrective: may do amniocentesis, Indocin (to ↓ fetal urine output)

43. Amniotic Fluid-Related Complications Oligohydramnios <500mL fluid or largest pocket of fluid on U/S is <5cm Associated with postmaturity, IUGR, major renal problem in fetus (malformation, blockage) If occurs early in preg, may cause fetal adhesions also fetal skin and skeletal abnormalities may occur, pulmonary hypoplasia, cord compression Tx: Monitor Amnioinfusion Fetal surgery

44. Complications of 3 rd and 4 th stage Retained placenta ☺ Lacerations: cervical or vaginal suspected when bright red bleeding in presence of well contracted uterus 1 st degree: fourchette, perineal skin, vag mucousa 2 nd degree: perineal skin, vag mucosa, underlying fascia, muscles of perineal body 3 rd degree: extends thru perineal skin, vag mucosa and perineal body and involves anal sphincter 4 th degree: same as 3 rd degree, but extends thru rectal mucosa to the lumen of the rectum

47. Intrauterine Fetal Demise (IUFD) May be found prior to coming to hosp or at time of admission May be unexplained or r/t materanal disease process or fetal insult May be induced right away or wait for spontaneous labor. C/S not automatically done Pain med give freely

48. Intrauterine Fetal Demise (IUFD) Provide privacy for families Listen Avoid inappropriate consolations Give accurate info Obtain mementos Allow opportunity to see and hold Provide information re: burial options Provide support information

49. 49 Premature Rupture of Membrane (PROM) Spontaneous break in the amniotic sac before onset of regular contractions Mother at risk for chorioamnionitis, especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours Risk of fetal infection, sepsis and perinatal mortality increase with prolonged ROM. Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus.

50. 50 PROM Signs of Infection Maternal fever Fetal tachycardia Foul-smelling vaginal discharge

51. 51 PROM Detecting Amniotic Fluid Nitrazine Ferning: Place a smear of fluid on a slide and allow to dry. Check results. If fluid takes on a fernlike pattern, it is amniotic fluid. Speculum exam

52. fernlike pattern

53. 53 PROM Treatment Depends on fetal age and risk of infection In a near-term pregnancy, induction within 12-24 hours of membrane rupture In a preterm pregnancy (28 -34 weeks), the woman is hospitalized and observed for signs of infection. If an infection is detected, labor is induced and an antibiotic is administered

54. 54 PROM Nursing Interventions Explain all diagnostic tests Assist with examination and specimen collection Administer IV Fluids Observe for initiation of labor Offer emotional support Teach the patient with a history of PROM how to recognize it and to report it immediately

55. 55 Signs of Preterm Labor Rhythmic uterine contraction producing cervical changes before fetal maturity Onset of labor 20 – 37 weeks gestation. Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies. There is no known prevention except for treatment of conditions that might lead to preterm labor.

56. 56 Treatment of Preterm Labor Used if tests show premature fetal lung development, cervical dilation is less than 4 cm, & there are no that contraindications to continuation of pregnancy. Bed rest, drug therapy (if indicated) with a tocolytic

57. 57 Preterm Labor Pharmacotherapies Terbutaline (Brethine), a beta-adrenergic blocker, is the most commonly used tocolytic Side effects: maternal & fetal tachycardia, maternal pulmonary edema, tremors, hyperglycemia or chest pain, and hypoglycemia in the infant after birth Ritodrine (Yutopar) is less commonly used.

58. 58 Preterm Labor Pharmacotherapies  Magnesium Sulfate  Acts as a smooth muscle relaxant and leads to decreased blood pressure  Many side effects including flushing, nausea, vomiting and respiratory depression  Should not be used in women with cardiac or renal impairment  Excreted by the kidneys

59. 59 Perterm Labor Pharmacotherapies Corticosteroids  Help mature fetal lungs  Betamethasone or dexamethasone  Most effective if 24 hours has elapsed before delivery

60. 60 Nursing Interventions with Preterm Labor Nursing Intervention in Premature labor  Observe for signs of fetal or maternal distress  Administer medications as ordered  Monitor the status of contractions, and notify the physician if they occur more than 4 times per hour.

61. 61 Nursing Interventions with Preterm Labor Nursing Intervention in Premature labor  Encourage patient to lie on her side  Bed rest encouraged but not proven effective  Provide guidance about hospital stay, potential for delivery of premature infant and possible need for neonatal intensive care

62. 62 Nursing Interventions with Preterm Labor Discharge teaching for home care:  Avoid sex in any form  Take medications on time  Teach to recognize the signs of preterm labor and what to do

63. Birth Related Procedures

64. Procedures Version External Internal Cervical Ripening Cervidil Cytotec Amnioinfusion ~250-500 mL warmed saline or LR is infused into uterus via IUPC over 20-30 min Used to correct variables, dilute mec stained fluid

65. Labor Induction Stimulation of U/C before spontaneous onset of labor Prior to starting induction Verification of gestation age Confirmation of fetal presentation Assessment of risk factors Well-being assessment of mom and baby Cervical Assessment

66. Labor Induction Cervical Assessment (Bishop’s Score) Higher the score, more successful the induction will be Favorable cervix is most important criteria for successful induction

67. Bishop’s Score) Cervical dilatation 1-23-45-6 Cervical effacement 0-4040-8080+ Position of cervix posteriormedialAnterior Consistency of cervix FirmMediumsoft Station of presenting part -2-1/0+1/+2

68. Labor Induction Methods Stripping membranes Oxytocin ☺Always given via IV pump (may be given IM after del) Site closest to insertion Continuous EFM Risks –Hyperstimulation –Uterine rupture –Water intoxication –Fetal risks associated with maternal problems, hyperbilirubinemia, trauma from rapid birth

69. Episiotomy Decline over the years May make it more likely will have deep tears Lacerations heal more quickly in absence of epis 3 rd or 4 th degree lacerations more likely with epis

70. Episiotomy Midline from vag orifice to fibers of rectal sphincter Less blood loss, easier to repair, heals with less discomfort Mediolateral From midline of posterier forchette to 45° angle to right or left Provides more room but has > blood loss, longer healing time and more discomfort Tx Pain relief measures Ice Inspect!

73. Operative Assisted Deliveries Forceps Maternal complications Trauma Increased pain in pp period Weakening of the pelvic floor Fetal-neonatal complications Caput Caphalohematoma Transient facial paralysis trauma

74. Operative Assisted Deliveries Vacuum Extractor Longer duration of suction, more likely scalp injury Maternal complications Perineal trauma Edema Genital tract and anal sphincter probs (< than with forceps) Neonatal complications Scalp lacerations Bruising/subdural hematoma Cephalohematoma Jaundice Fx clavicle Retinal hemorrhage death

75. Cesarean Birth 1970 - ~5% 1988 – 24.7% 2001 – 21% 2005 - ? But higher Indications Failure to progress/descend Previa/abruption/prolapse cord Non-reassuring fetal status Malpresentation Previous C/S Maternal morbidity and mortality is > than vag delivery

76. Cesarean Birth Technique NOTE: Skin incision NOT indicative of uterine incision Transverse (Pfannenstiel)-lower uterine segment Adv: below pubic hair line, less bleeding, better healing Disadv: difficult to extend if needed, requires more time, if adipose fold difficult to keep clean and dry Vertical-between naval and symphysis Adv: quicker, more room Disadv: scar obvious, longer

77. Cesarean Birth

79. Technique Uterine incision (type depends on need for C/S) Transverse-lower uterine segment Adv: thinnest  less blood loss, only mod dissection of bladder, easier to repair, site less likely to rupture during subsequent pregnancies, less chance of adherence of bowel or omentum to incision line Disadv: takes longer, limited in size due to major blood vessels, greater tendency to extend into uterine vessels

80. Cesarean Birth Technique Lower Uterine Segment Vertical Incision Preferred for multiple gestation, abnormal presentation, previa, preterm, macrosomia Adv: more room Disadv: may extend into cx, more extensive dissection of the bladder is necessary, if extends upward hemostasis and closure more difficult, higher risk of rupture in subsequent pregnancies

81. Cesarean Birth Technique Classic incision Upper uterine segment Adv: more room, quicker to do Disadv: more blood loss, difficult to repair, higher risk of rupture in subsequent pregnancies

82. Cesarean Birth Prep for C/S (time dependent) Permits NPO IV Oral/IV antacids, H2 inhibitors FoleyTeaching Shave Immediate PP care Freq vs (q 5-10 min) Lungs Check dressingI&O Lochia and uterus Anesthetic level

83. VBAC (vaginal birth after cesarean) That was then, this is now Specific criteria Must sign consent Contraindications Classic incision or previous fundal uterine surgery Most common risk is hemorrhage and uterine rupture

84. Placental accreta occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle. Placenta accreta is the most common accounting for approximately 75% of all cases. Approximately 1 in 2,500 pregnancies experience placenta accreta, increta or percreta. There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall.

85. Placental increta occurs when the placenta attaches even deeper into the uterine wall and does penetrate into the uterine muscle. Placenta increta accounts for approximately 15% of all cases.

86. Placental percreta occurs when the placenta penetrates through the entire uterine wall and attaches to another organ such as the bladder. Placenta percreta is the least common of the three conditions accounting for approximately 5% of all cases.

87. Deep attachment to uterine wall

88. management Treatment: Managing placenta accreta requires controlling hemorrhaging; removing the placenta that has adhered to the uterine wall is very difficult and can result in blood loss. If the diagnosis is made before labor begins, a cesarean section should be performed whenever possible and blood products should be readily availablecesarean section In the majority of cases, a hysterectomy remains the treatment of choice.