Complication o Labor

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 1st 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 bescheduled 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 3rd or 4th 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

17. Abruptio Placentae

18. Abruptio Placentae • http://video.about.com/pregnancy/Placenta-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. Abruptio Placentae • 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

27. Placenta Previa

28. Placenta Previa

29. Placenta Previa

30. Placenta Previa • 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. 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 3rd and 4th stage • Retained placenta • ☺Lacerations: cervical or vaginal suspected when bright red bleeding in presence of well contracted uterus • 1st degree: fourchette, perineal skin, vag mucousa • 2nd degree: perineal skin, vag mucosa, underlying fascia, muscles of perineal body • 3rd degree: extends thru perineal skin, vag mucosa and perineal body and involves anal sphincter • 4th degree: same as 3rd 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. 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. PROMSigns of Infection • Maternal fever • Fetal tachycardia • Foul-smelling vaginal discharge