Complications of Labor and Delivery by: Ann Hearn RNC, MSN Spring 2009

1. Complications of Labor and Deliveryby: Ann Hearn RNC, MSN Spring 2009

2. The Powers Complications • Uterine Dystocia -defined as difficult labor. • Hypertonic contractions– more frequent but decreased intensity • Hypotonic contractions– decrease in frequency (2-3 UC in 10 min period) • Also termed uterine inertia

3. Interventions for Uterine Dystocia Hypertonic Uterus: Contractions are painful but ineffective resulting in prolonged latent phase. • Nursing Interventions: • Bed rest • Sedation or pain relief • Support/educate • Position changes • Comfort measures: calm environment, music, therapeutic touch, back rub, warm shower, imagery

4. Interventions for Uterine Dystocia Hypotonic Uterus: results from overstretched uterine muscle leading to a prolonged active phase. • Nursing Interventions: • Amniotomy • Pitocin administration • Emptying bladder • Hydration • Teaching/Support

5. Amniotomy/Artificial Rupture of Membranes (AROM) • Advantages: • Increases frequency and intensity of uterine contractions • Release of prostaglandins • Facilitates decent of presenting part • Allows for internal monitoring • Ability to assess amniotic fluid • Disadvantages: • Increased risk for infection • Possibility of prolapsed umbilical cord

6. Artificial Rupture of Membranes Fig. 20-1d

7. Amniotomy/Artificial Rupture of Membranes (AROM) • Nursing care • Place disposable pads and towel under-buttock and change frequently • Assess FHR before and after amniotomy • Contraindication: **Procedure should not be performed if head is not engaged**

8. Bishop Score • Pre-labor status evaluation scoring system • A predictor for the potential success of induction of labor • A high score indicates the cervix is favorable and vaginal delivery will likely occur

9. Induction of LaborBishop Score

10. Pitocin (Oxytocin) Administration Uses of Pitocin: • Induction – initiates uterine contractions • Augmentation– enhances ineffective contraction pattern Goal: A labor pattern with uterine contractions occurring every 2-3 minutes, lasting 40-60 seconds and a return to baseline between contractions

11. Indications for Induction (ACOG, 1999) • Diabetes mellitus • Renal disease • Preeclampsia • Premature rupture of membranes • History of rapid labor • Chorioamnionitis • Postterm gestation • Mild abruptio placenta • IUFD • IUGR

12. Pitocin (Oxytocin) Administration • Nursing interventions when titrating Pitocin: • maternal V/S • FHR pattern • Baseline • Variability • Periodic changes • Uterine contraction pattern • Frequency • Duration • Interval

13. Failure to Progress Prolonged Labor • Causes: • Labor dystocia • Malposition • Malpresentation • Macrosomia • Interventions: • R/O CPD • Uterine rest • Pitocin augmentation

14. Precipitous Labor Labor < 3 hours • Complications: • Woman • loss of coping ability • Lacerations of cervix, vagina, perineum • Fetus • Hypoxia • Cerebral trauma • Pnemothorax

15. Precipitous Labor 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?

16. The Passenger

17. Malposition of the Fetus • Medical Treatments: • Rotation and delivery by: • forceps • vacuum assisted devise

18. Internal & External Rotation (version) A procedure performed to change the fetal presentation • Internal • Podalic- changing the position of the 2nd twin after delivery of the 1st via vaginal manipulation • External • Manual rotation of the fetus from breech to cephalic presentation via external manipulation of the maternal abdomen

19. External Version Fig. 20-3

20. Three Malpresentations • Brow: forehead • C/S delivery • Face • Vaginal delivery • Breech • Frank – buttocks • Footling – foot/feet • C/S delivery

21. Obstetric Forceps Fig. 20-4 Middle row

22. Obstetric Forceps (cont’d) Fig. 20-4 Last row

23. Birth Assisted with a Vacuum Extractor Fig. 20-5

24. Cephalo-pelvic DisproportionCPD Fetus is larger than the pelvic diameter • Hallmark symptom is failure of the fetus to descend Causes: • diseases affecting bones (rickets), injury • congenital anomolies, pelvic shape & size

25. Cephalo-pelvic DisproportionCPD • Diagnosis • CT scan • Estimated fetal weight per US • Trial of labor • Borderline pelvic diameter • Support patient • Keep the patient informed of progress • Position changes: sitting squatting, hands & knees may help with descent • Prepare for possible C/S

26. Skin Incisions for Cesarean Birth Fig. 20-8

27. Uterine Incisions for Cesarean Birth Fig. 20-9

28. Vaginal Delivery After Cesarean Section - VBAC Increased risk for uterine rupture • Obtain informed consent • Nursing Implications • Large bore IV access • Continuous EFM

29. Premature Rupture of Membranes - PROM Spontaneous rupture of membranes prior to the onset of labor • Associated conditions: • Infection • Previous history of PROM • Hydramnios • Multiple pregnancy • UTI • Trauma

30. Premature Rupture of Membranes - PROM • Determine time of PROM • Verification of PROM: • Visualization • Sterile speculum exam • pH

31. Premature Rupture of Membranes - PROM • Nursing Assessment • Vital signs (temp q 2hr) • Fetal monitoring • Nature of fluid • WBC count • Administration of Celestone - betamethasone • PPROM: preterm

32. 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

33. Preterm Labor • Fetal Fibronectin test • 99% accurate predictor of NO preterm birth within 7 days • Nursing Implications • Promote rest, hydration, circulation • Monitor FHR and uterine activity • Administer tocolytics as ordered

34. Preterm Labor Tocolytics • Medications prescribed to stop preterm labor • Terbutaline – B adrenergic receptor antagonist • Magnesium sulfate – CNS depressant • Ritodrine - not FDA approved for PTL rarely used.

35. Tocolytic Drugs Smooth muscle relaxants Terbutaline Contraindications: hold and notify HCP if maternal HR > 140bpm • Side effects: increase heart rate, feeling of anxiety, headache, increased blood glucose Magnesium Sulfate • Contraindications: discontinue for resp. depression, magnesium level >8, administer ca+ gluconate • Side Effects: flushing, headache, nausea, lethargy, dizziness, decreased DTR, decreased resp. rate, pulmonary edema

36. Ruptured Uterus • Causes: • Long difficult labor • Injudicious use of Pitocin • Previous C/S • Assessment Findings • Fetal bradycardia • Maternal abdominal pain • Obstetrical Treatment • Emergency Cesarean Section delivery

37. Uterine Rupture

38. 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

39. Variations of Prolapsed Umbilical Cord Fig. 27-6a

40. Variations of Prolapsed Umbilical Cord (cont’d) Fig. 27-6c

42. Amniotic Fluid Embolism 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

43. Amniotic Fluid Embolism Assessment Findings: Sudden onset • Respiratory distress (dyspnia) • Circulatory collapse (cyanosis) • Tachycardia • Hypotension • Acute hemorrhage • Cor Pulmonale • Frothy sputum

44. Amniotic Fluid Embolism Obstetrical Emergency • Interventions: • Large bore IV line • Positive pressure oxygen • CPR • Blood transfusion - DIC • Emergency C/S if pregnant Prognosis – 50% of women die with the first hour of symptoms