1. MATERNAL/NEWBORN NURSING COMPLICATIONS OF LABOR & DELIVERY PP by Tara Daly, RN, MSN

2. LEARNINNG OBJECTIVES At the end of this lesson, the SPN will be able to describe the etiology, pathophysiology, treatment and nursing management for a patient with postpartum complications

3. COMPLICATIONS OF LABOR & DELIVERY Dystocia Prolapsed Cord Ruptured or Inverted Uterus Retained Placenta Lacerations Hematoma infection

4. COMPLICATIONS OF LABOR & DELIVERY Dystocia Is a long, difficult, or abnormal labor caused by any of the 4 major variables (4Ps) that affect labor. The labor does not progress

5. DYSTOCIA The following may be causes: Dysfunctional labor: ineffective contractions or maternal pushing efforts (powers) Pelvic structure variations (passage) Fetal variations: anomalies, abnormal presentation or position, very large size, or number of fetuses (passenger) Mother’s responses: related to preparation for childbirth, past experiences, culture, & support person (psyche)

6. DYSTOCIA LET’S DISCUSS IN DETAIL EACH OF THE 4 MAJOR VARIABLES!

7. DYSTOCIA Dysfunctional Labor Is a labor with problems of the contractions or with maternal bearing down efforts The contractions may be hypertonic or hypotonic

8. DYSTOCIA Dysfunctional Labor Hypertonic Uterine contractions Contractions are poorly coordinated, frequent, and painful Uterine resting tone between contractions is tense It is more likely to occur during latent labor, before 4 cm of cervical dilation

9. HYPERTONIC UTERINE CONTRACTIONS  Common causes are cephalopelvic disproportion (CPD) (discussed later), malposition of the fetus, an overstretched uterus from multiple fetuses, a fetus of very large body size, hydraminos, or grand-multiparity (having delivered more than 6 infants)

10. HYPERTONIC UTERINE CONTRACTIONS The risks for the mother include intrauterine infection, especially if the membranes are ruptured and labor is prolonged; postpartum hemorrhage caused by inefficient uterine contractions after birth; exhaustion; and decreased coping ability. The fetus may experience distress because of the length of labor & sepsis from maternal pathogens ascending the birth canal.

11. HYPERTONIC UTERINE CONTRACTIONS An ultrasound is usually performed to rule out CPD. If all factors are normal, one or more measures for augmentation of (increasing) labor are instituted, including ambulation, enema, amniotomy, nipple stimulation, & oxytocin infusion.

12. oxytocin (Pitocin) stimulates uterine contractions stimulates uterine contractions –Nursing observations during induction/augmentation  Fetal heart rate  Character of contractions –If abnormality occurs, nurse stops oxytocin and begins measures to reduce contractions and increase placental blood flow

13. HYPOTONIC UTERUS Weak, irregular, ineffective, or uncoordinated contractions. Early labor pattern may be normal, but cervical dilation slows and then stops. It occurs during the active phase, after 4 cm of cervical dilation Causes: oversedation from drugs, anxiety, fatigue, overdistention of the uterus due to multiple pregnancy, CPD, macrosomnia RX: Amniotomy, Hydration, rest, ambulation, and oxytocics.

14. AMNIOTOMY A vaginal exam is performed Determine dilatation Effacement Presenting Part Station FHR

15. AMNIOTOMY Amniotomy Artificial rupture of membranes (AROM) Linens placed under patient to absorb amniotic fluid Plastic disposable hook used

16. AMNIOTOMY  After an amniotomy  FHR assessed for one full minute  Amniotic fluid odor, color, and quantity are documented  The fluid should be clear (sometimes flecks of vernix are present), with a mild odor, greenish meconium-stained fluid may indicate placental insufficiency  Foul-smelling fluid or fluid with a strong odor with a cloudy appearance or yellow color often indicates chorioamnionitis

17. PELVIC STRUCTURE VARIATIONS Small or abnormally shaped pelvis may experience a long & difficult labor. Only about 50% of women have the pelvic shape (gynecoid) most conducive to labor, fetal descent, and birth. A distended bladder reduces space available in the pelvis and is an obstruction to fetal descent.

18. FETAL VARIATIONS Variations of the fetus may cause dystocia include the following: *Anomalies *Abnormal presentation *Size *Number of fetuses

19. FETAL VARIATIONS Anomalies Example Hydrocephalus may prevent descent of the fetus

20. FETAL VARIATIONS Abnormal Presentation or Position A cephalic presentation other than vertex makes a larger diameter of the fetal head move through the birth canal. Labor takes longer & is more difficult In a breech presentation, cervical effacement & dilatation are often slower because the buttocks are softer than the head & do not put firm pressure on the cervix to aid in dilation.

21. BREECH PRESENTATION Following are risks to the fetus born in a breech presentation: Cord compression Aspiration of fluids in the vagina Head becoming stuck

22. BREECH PRESENTATION External Version Manipulation of the fetus through the mother’s abdomen to a presentation facilitating birth It is not always possible to change the presentation of the fetus

23. ABNORMAL PRESENTATION OR POSITION A position of occiput posterior or occiput transverse can contribute to dysfunctional labor. Labor is longer because the head has farther to rotate during internal rotation. Many women c/o severe back and leg pain.

24. ABNORMAL PRESENTATION OR POSITION A change in the mother’s position may promote rotation of the fetal head. When the mother’s abdomen is dependent to her spine, as in the hands-and-knees position, fetal rotation is encouraged.

25. CEPHALOPELVIC DISPROPORTION Cause can be either fetal or maternal Whatever the cause a cesarean birth is required.

26. SIZE An infant weighing more than 4,000 g (8.8 lb) is said to be macrosomic (having a very large body size). *This may cause problems for a vaginal birth. *When the head will not fit through the mother’s pelvis, it is called cephalopelvic disproportion (CPD)

27. NUMBER OF FETUSES When more than one fetus is present, the uterus is over-distended. One or more of the fetuses may be in a presentation less desirable than vertex. Twins are often cesarean birth, and when there are three or more, birth is almost always cesarean

28. DYSTOCIA Mother’s Response Mother’s perception is more important than her actual experience in labor.

29. MOTHER’S RESPONSE Excessive or prolonged stress may interfere with the progress of labor in several ways: Secretion of catecholamines (epinephrine & norepinephrine) by the adrenal glands in response to stress inhibits uterine contractions & decreases blood supply to the uterus & placenta while increasing blood supply to the skeletal muscles.

30. MOTHER’S RESPONSE Stress Tense abdominal & pelvic muscles making contractions less effective. Contractions working against tense abdominal muscles, increase pain, which adds stress to the situation & makes mother more anxious.

31. COMPLICATIONS OF LABOR & DELIVERY Prolapsed Cord When the umbilical cord lies below the presenting part of the fetus. May occur anytime and may be hidden or visible.

32. PROLAPSED CORD Most commonly occurs with ROM, either spontaneous rupture of membranes (SROM) or AROM. Pressure on umbilical cord that interferes with fetal oxygenation As the cord washes down with amniotic fluid. Happens in 1 of 400 births

33. PROLAPSED CORD A cord below the presenting part is compressed between the fetus & the mother’s pelvis, resulting in decreased blood flow to the fetus. Fetus will have bradycardia with variable decelerations during uterine contractions.

34. PROLAPSED CORD Contributing Factors include: A long cord (greater than 40 inches) Unengaged presenting part Breech presentation Prematurity, small fetus Excessive amniotic fluid Low implantation of the placenta

35. PROLAPSED CORD Once identified, pressure on the cord must be relieved immediately. MD inserts two fingers into the vagina, and puts pressure on the presenting part to relieve the compression of the cord. Patient is then placed into a modified Sim’s position with her hips up on pillows, the knee-chest position or Trendelenburg

36. PROLAPSED CORD The knee-chest position allows gravity to keep the pressure on the presenting part off the cord. IV started; O2 @ 6-10 L Occasionally, a vaginal birth may be possible, but generally a cesarean birth is preferred.

37. RUPTURED UTERUS A tear in the uterine wall occurs if the muscle cannot withstand the pressure inside the organ.

38. RUPTURED UTERUS Risk Factors: Previous C-section Oxytocic drugs Multigravidity Blunt abdominal trauma ie. An automobile accident, etc.

39. UTERINE RUPTURE 3 variations of uterine rupture: Complete rupture; there is a hole through the uterine wall, from the uterine cavity to the abdominal cavity.

40. UTERINE RUPTURE Incomplete Rupture The uterus tears into a nearby structure, such as a ligament, but not all the way into the abdominal cavity.

41. UTERINE RUPTURE Dehiscence An old uterine scar, usually from a previous cesarean birth, separates.

42. UTERINE RUPTURE Signs & Symptoms May be asymptomatic May have sudden onset of severe signs and symptoms, such as the following: Shock caused by bleeding into the abdomen; vaginal bleeding may be minimal Abdominal Pain Pain in the chest, between the scapulae, or with inspiration

43. UTERINE RUPTURE S & S Cessation of contractions Abnormal or absent fetal heart tones Palpation of the fetus outside the uterus because the fetus has pushed through the torn area.

44. UTERINE RUPTURE  Medical Treatment  If fetus is living when the rupture is detected and/or if blood loss is excessive, the MD performs surgery to deliver the fetus & to stop the bleeding. Hysterectomy is likely for an extensive tear. Smaller tears may be surgically repaired

45. INVERTED UTERUS Occurs if the uterus turns inside out after the infant is born. Inversion may be partial or complete. The MD may note a small depression in the top of the uterus or that the uterus is not in the abdomen & protrudes from the vagina with its inner surface showing. Rapid onset of shock is common.

46. UTERINE INVERSION More likely to occur if the uterus is not firmly contracted, especially if the cord has been pulled on to deliver the placenta. Inversion can also occur during vigorous fundal massage when the fundus is not firm and is pushed downward toward the pelvis.

47. UTERINE INVERSION Medical Treatment MD will try to replace the inverted uterus while the woman is under general anesthesia. An anesthetic agent is chosen to cause uterine relaxation; tocolytic drugs may also be used. After the uterus is replaced, oxytocin is given to contract the uterus & control bleeding. If replacement is not successful, hysterectomy may be required.

48. RETAINED PLACENTA Within 5 to 30 minutes of delivery, the placenta usually follows the same path that the baby just took out of the body. In about 1 out of every 100 to 200 deliveries, the placenta is “retained” in the uterus. A retained placenta is often accompanied by heavy bleeding.

49. RETAINED PLACENTA Manual Removal May be done in the delivery room or the OR. MD places hand inside the uterus & gently separates the placenta from the wall of the uterus. Maybe uncomfortable; pain medication, spinal or epidural anesthetic, or general anesthesia may be needed.

50. RETAINED PLACENTA Manual Removal Oxytocin & Methergine are often given to help the uterus contract & help prevent bleeding. Antibiotics given to reduce the risk of uterine infection. Rarely, the placenta will not separate, and cannot be removed completely. May have significant bleeding and often requires emergency hysterectomy. Blood transfusions are common.

51. LACERATIONS Due to rapid, difficult, breech delivery, large fetal head, use of forceps. an indication is a firm fundus and bright red bleeding

52. LACERATIONS Classified according to degree of tissue tearing; 1 st degree-skin and MM 2 nd degree-skin, MM, and muscles 3 rd degree-skin, MM, muscles, rectal sphincter 4 th degree-skin, MM, muscles, rectal sphincter and anal wall

53. LACERATIONS They are repaired by suturing the tissue.

54. HEMATOMA Collection of blood in tissue beneath the skin in the genitalia or vaginal mucosa. Causes: Birth trauma, forceps trauma

55. HEMATOMA  S & S  Severe perineal pain  A sensitive bulging covered by discolored skin in the perineum  Inability to void  Uterus is firmly contracted  Lochia amounts are w/i normal limits  Mom’s blood pressure falls  Tachycardia  Hematomas in the vagina cannot be readily seen

56. HEMATOMA RX: If small, allowed to be reabsorbed If large, surgical incision & drainage Analgesics Ice Positioning Foley Catheter Sitz baths

57. INFECTION Puerperal Infection Infection of the reproductive tract during PP period (birth to 6 weeks) Vagina, endometrium, episiotomy site, etc. Infections are classified by site

58. INFECTION Endometritis-infection of the uterine lining Parametritis-connective tissue around the uterus Peritonitis-pelvic cavity infection Vulvitis-vulva-external genitalia Vaginitis-vagina Local infections-cervix, episiotomy, laceration

59. INFECTION S & S’s Temp of 100.4 on 2 consecutive days during the 1 st 10 days PP Rapid pulse, malaise, chills, headache Pain & tenderness in the area involved Local infections will produce purulent drainage. Endometritis will produce greenish, foul smelling lochia.

60. INFECTION RX: C&S specs IV antibiotics Fluids VS Semi-Fowlers position to facilitate drainage Sitz baths for local infections of perineum Mother may not be able to care for her infant