Complications of Labor & Delivery

1. Complications of Labor & Delivery Fall 2012

2. Dysfunctional Labor • Normal labor is characterized by progress. • Dystocia is a general term that applies to any difficult labor or birth. • Causes • The Powers • The Passenger • The Passageway • The Psyche

3. Complications of The Powers • Ineffective uterine contractions • Uterine Dystocia • Hypertonic Contractions • Hypotonic Contractions • Ineffective Maternal Pushing

4. Uterine Dystocia • Hypotonic contractions • Weak • Infrequent • Short • Pt comfortable • Nursing interventions • Walking • Position changes • Amniotomy • Oxytocin

5. Hypertonic Contractions • Uncoordinated and eratic • Painful but ineffective • Usually occurs in latent phase • High resting tone • Maternal fatigue • Nursing interventions • Pain management • Promote relaxation • Analgesics • Oxytocin or amniotomy • Tocolytics may be ordered

6. Ineffective Pushing • Incorrect technique • Fear • Decreased urge • Exhaustion

7. Complications of the Passenger • Fetal Size • Malpositions • Malpresentations • Multifetal pregnancy • Fetal Anomalies

8. Interventions • Vacuum extraction • Forcep delivery • Risks of both to the baby • Risks of both to the mother

9. Complications of the Passageway • Pelvis • Pelvic Dystocia (Cephalopelvic Disproportion) • Bladder • Interventions

10. 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?

11. Problems of the Psyche • Pain • Stress • Fear • Support

12. Abnormal Labor Duration • Prolonged Labor • Once in active phase should proceed at 1-2 cm/hr • Risk Factors • Nursing interventions • Precipitous Labor • Birth that occurs within 3 hours of the onset of labor • Causes • Nursing interventions

13. Premature Rupture of Membranes Spontaneous rupture of membranes prior to the onset of labor • Associated conditions: • Infection • STDs, UTI, GBS • Previous history of PROM • Amniotic sac with a weak structure • Fetal abnormalities • Overdistention of the urterus • Maternal stress • Trauma

14. Premature Rupture of Membranes (PROM) Determine time of PROM Verification of PROM: Visualization Sterile speculum exam for ferning pH

15. Nursing Assessment • Vital signs (temp q 2hr) • Fetal monitoring • Nature of fluid • WBC count • Administration of Celestone - betamethasone • PROM: preterm • If leak seals, discharge instructions

16. 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

17. Cervical Length • Fetal Fibronectin test • 99% accurate predictor of NO preterm birth within 7 day • Infections

18. Preventing Preterm Birth • Treat the underlying cause • Preeclampsia • Hypovolemia • Serious Infection • Promote rest • Hydration

19. Medications • Tocolytics • Medications prescribed to stop preterm labor • Terbutaline – B adrenergic receptor agonist • Indomethacin- Prostaglandin inhibitor • Magnesium sulfate – CNS depressant • Nifedipine - Calcium channel blocker

20. Accelerating Fetal Lung Maturity • Necessary if infant < 34 weeks (24-34 weeks) • Betamethasone • Every 7 days • Birth should be delayed by 24 hours

21. Intrapartum Emergencies

22. 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

23. Prolapsed Umbilical Cord

25. Ruptured Uterus • Causes: • Long difficult labor • Injudicious use of Pitocin • Dehisence • High parity • Blunt abdominal trauma

26. Manifestations • Pain • Chest pain • Hypovolemic shock • Impaired fetal oxygenation • Absent fetal heart sounds • Cessation of uterine contractions • Palpation of fetus

27. Nursing considerations • Identify the risks • Use oxytocin cautiously • Monitor bleeding

28. Ruptured Uterus

29. Anaphylactoid Syndrome(Amniotic Fluid Embolus) 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

30. Assessment Findings: Sudden onset • Respiratory distress (dyspnea) • Circulatory collapse (cyanosis) • First the right ventricle, then left • Tachycardia • Hypotension • Acute hemorrhage • DIC

31. Obstetrical Emergency • Interventions: • CPR • Mechanical ventilation • Correction of hypotension • Blood transfusion - DIC • Emergency C/S if pregnant Prognosis – 50% of women die with the first hour of symptoms