Complicated Labor Patterns Complications of Labor & Delivery

1. Complicated Labor Patterns Complications of Labor & Delivery NUR 264

2. If was not supposed to be hard work, it would not have been called LABOR. • Anonymous

3. Characteristics of Tachysystole Labor • Increase contraction frequency • < 2 min frequency, > 90 seconds duration • Decrease contraction intensity • Increase uterine resting tone > 20 mm Hg • Prolonged latent phase • Painful due to uterine muscle anoxia • Ineffective in dilating and effacing cervix

4. Implications of Tachysystole Labor (cont’d) • Maternal exhaustion, dehydration, infection • Reduced uteroplacental exchange resulting in nonreassuring fetal status • Prolonged pressure on fetal head resulting in: • Excessive molding • Caput succedaneum • Cephalhematoma

5. Effects of labor on the fetal head. A, Caput succedaneum formation. The presenting portion of the scalp area is encircled by the cervix during labor, causing swelling of the softtissue. B, Molding of the fetal head in cephalic presentations: (1) occiput anterior, (2) occiput posterior, (3) brow, (4) face.

6. Nursing Plan for Tachysystole Labor • Stop oxytocin • Increase IV rate • Administer O2 by face mask • Position in side-lying position • Provide support and encouragement • Monitor contractions and fetal status • Notify health care provider • Assist with amniotomy • Administer pharmacologic agents as ordered – sedation • Monitor maternal fatigue

8. Hypotonic Labor • < 2 to 3 contractions in 10 minutes • Causes: • Fetal macrosomia • Multiple gestation • Hydramnios • Grand multiparity • CPD

9. Implications of Hypotonic Labor • Help with coping abilities • Prolonged labor results in: • Maternal exhaustion, dehydration • Increased incidence of infection • Postpartum hemorrhage due to uterine atony • Nonreassuring fetal status • Fetal sepsis from pathogens ascending from birth canal

10. Nursing Plan for Hypotonic Labor • Frequent monitoring of vital signs, FHR and contractions • Assist with amniotomy – assess amniotic fluid for meconium • Administer oxytocin or nipple stimulation • Assess bladder for distention and empty every 2 hours • Minimize vaginal exams to decrease risk of infection

11. Nursing Plan for Hypotonic Labor (cont’d) • Assess for signs of infection • Maternal fever • Chills • Foul-smelling amniotic fluid • Fetal tachycardia • Provide emotional support • Provide information and encourage questions • Prepare for surgical delivery

12. Abnormal Presentation/Dystocia • Abnormal flexion of head, breech, twins • Large fetus – macrosomia • CPD, shoulder dystocia • Poor quality contractions - prolonged labor • Extensive perineal laceration at birth (3rd or 4th degree) or vaginal trauma • Increased fetal morbidity and mortality

13. Abnormal Presentations

14. Breech Presentations • Likely cesarean birth • Increased risk of prolapsed cord • Increased risk of cervical spinal cord injuries due to hyperextension of fetal head during vaginal birth • Increased risk birth trauma (especially head) during any type of birth

15. Breech Presentations

16. Multiple Gestation • Frequent assessment of fetal heart tones of each fetus • Education of mother about signs and symptoms of preterm labor • Encouragement of mother to rest frequently prior to birth • Preparation of equipment needed to care for each individual newborn

17. Multiple Gestation

18. Multiple Gestation

19. Cephalopelvic Disproportion • Occurs when fetal head is larger than maternal pelvic diameter • Lack of fetal descent in presence of strong contractions • Labor usually prolonged

20. Cephalopelvic Disproportion (cont’d) • Increase pelvic diameter during labor by squatting, sitting, rolling from side to side, maintaining knee-chest position, use of a labor ball - AVOID lithotomy! • Vaginal birth may be possible depending upon type of CPD • CPD may make cesarean only available method of birth

21. Fetal Macrosomia • Newborn weighing more than 4500 g or more • May be postterm, IDM • Identification of fetal macrosomia is conducted through • Palpation of fetus in utero • Ultrasound of fetus • X-ray pelvimetry • Shoulder Dystocia

22. Management of Fetal Macrosomia • Continuous fetal monitoring if labor is allowed to progress • Requires notification of health care provider for early decelerations, labor dysfunction, or nonreassuring fetal status • McRobert’s manuever – legs to chest & suprapubic pressure • Cesarean birth performed if fetus is greater than 4500 g

23. Shoulder Dystocia McRobert’s Maneuver

24. Care of Mother • Care of mother after birth of newborn with macrosomia requires: • Fundal massage to prevent maternal hemorrhage from overstretched uterus • Close monitoring of vital signs and vaginal blood flow

25. Care of Newborn • Care of newborn with macrosomia requires assessment of newborn for: • Cephalhematoma • Erb's palsy • Fractured clavicles • Anoxia • Cord prolapse

26. Implications of Hydramnios • Rh sensitization • Malformations of fetal swallowing • Neural tube defects with exposed meninges • Anencephaly • Cardiac anomalies • Esophageal or duodenal atresia • Provide information and emotional support

27. Nursing Plan for Oligohydramnios • Reduced AFI • Evaluate EFM tracing for variable decels or nonreassuring fetal status • Reposition mother to relieve cord compression • Notify clinician of signs of cord compression • Evaluate newborn • Anomalies of skin & skeleton, adhesions • Pulmonary hypoplasia • Renal agenesis, lower UTI obstructive lesions • Postmaturity

28. Cord Prolapse • Umbilical cord precedes fetal presenting part placing pressure on cord and diminishing blood flow to fetus • Bed rest is recommended if engagement has not occurred and membranes have ruptured • Assess for nonreassuring fetal status

29. Cord Prolapse • Examiner’s fingers must remain in vagina • Have patient assume knee-chest position, Trendelenburg position, or side-lying position with hips elevated on pillow (head/chest up if epidural) • Apply O2 at 8 – 10 L/min • Vaginal birth may be attempted if completely dilated and pelvic measurements adequate • Cesarean section is delivery of choice

30. Precipitous Delivery • Precipitous birth is one that occurs rapidly without physician or certified nurse-midwife in attendance • Mother may fear what is going to happen and feel that everything is out of control • Mother needs to assume comfortable position

31. Precipitous Delivery (cont’d) • Nurse scrubs his or her hands if time permits – applies gloves • When infant's head crowns, mother should pant • Gentle pressure is applied against fetal head to prevent it from popping out rapidly • Perineum is supported and head is born between contractions 

32. Postterm Pregnancy • Postterm pregnancy may result in an increased possibility of • Probable labor induction • Forceps or vacuum-assisted or cesarean birth • Decreased perfusion to the placenta • Decreased amount of amniotic fluid and possible cord compression • Meconium aspiration • Macrosomia or a loss of fat and muscle mass resulting in small-for-gestational age (SGA) newborn

33. TABLE 21–3 Placental and Umbilical Cord Variations

34. TABLE 21–3 (continued) Placental and Umbilical Cord Variations

35. Manual Removal of Placenta

36. Amniotic Fluid Embolism • Amniotic fluid & fetal cells enter bloodstream • Triggers immune response similar to anaphylactic shock • Results in pulmonary artery vasospasm, pulmonary hypertension, hypoxia • Then hemorrhage and DIC

37. S/S of Amniotic Fluid Embolism • Sudden onset resp. distress - dyspnea • Cyanosis • Frothy sputum • Chest pain, cor pulmonale • Tachycardia, severe hypotension • Mental confusion • Massive hemorrhage, DIC, shock • Coma and maternal death • Fetal death if birth not immediate

38. Nursing Plan for Amniotic Fluid Embolism • Summon emergency team • Positive pressure oxygen delivery • Large bore IV • CPR as needed • Prepare for cesarean, if birth has not occurred and neonatal resuscitation • Prepare for CVP line insertion • Administer blood, hypotensive drugs, steroids • 85% maternal survivors and 50% fetal survivors have neuro damage

39. Birth-related Procedures

40. Vacuum Extractor • Assists birth by applying suction to fetal head • Should be progressive descent with first two pulls, procedure should be limited to prevent cephalhematoma - Risk increases if birth not within six minutes • Increases risk for jaundice - Due to reabsorption of bruising at cup attachment site

41. Vacuum extractor traction. A, The cup is placed on the fetal occiput and suction is created. Traction is applied in a downward and outward direction. B, Traction continues in adownward direction as the fetal head begins to emerge from the vagina. C, traction is maintained to lift the fetal head out of the vagina.

42. Risks of Forceps • Monitor FHR during procedure • Assess newborn for: • Bruising • Edema • Facial lacerations • Cephalhematoma • Transient facial paralysis • Cerebral hemorrhage

43. Risks of Forceps (cont’d) • Empty bladder prior to procedure • Assess patient for: • Vaginal or perineal lacerations • Infection secondary to lacerations • Increased bleeding • Bruising • Perineal edema • Bladder injuries

44. Application of forceps in occiput anterior (OA) position. A, The left blade is inserted alongthe left side wall of the pelvis over the parietal bone. B, The right blade is inserted along theright side wall of the pelvis over the parietal bone. C, With correct placement of the blades, the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal.

45. Indications for Cesarean Section • Most common indications for cesarean birth • Fetal distress • Active genital herpes • Multiple gestation (three or more fetuses) • Umbilical cord prolapse • Tumors that obstruct birth canal • Lack of labor progression • Maternal infection • Pelvic size (cephalopelvic) disproportion • Placenta previa or abruptio placenta • Previous cesarean section • Fetal malpresentation

46. Preparation for C/S • Preparation for cesarean birth requires • Obtaining consent • Obtaining V/S and FHR • Establishing IV lines • Inserting indwelling urinary catheter • Performing abdominal prep • Maintaining NPO status • Administering preop medications

47. Teaching C/S • Teaching needs include • What to expect before, during, and after delivery • Why is it being done • What sensations will the patient experience • Role of significant others • Turn, cough, deep breathe instruction • Early ambulation • Interaction with newborn

48. Pfannenstiel Classical Incision Incision increased risk of uterine rupture in subsequent pregnancies and labor.

49. Nursing Care C/S • Routine postpartal care including: • V/S and Fundus checks • Care of incision • Monitoring intake and output • Maintain IV access • Administer and teach about post-op medications • Assessment of respiratory system • Assessment of bowel sounds

50. Vaginal Birth After Cesarean Birth • Can occur after trial of labor in cases of nonrecurring indications for cesarean birth • Most common risks are • Hemorrhage • Surgical injuries • Uterine rupture • Infant death or neurological complications • Classic or T uterine incision is contraindication to VBAC