L&D Complications Lecture 11

1. L&D ComplicationsLecture 11

2. Dystocia: “prolonged labor” difficult labor. Shoulder dystocia: difficult birth d/t shoulders. Indicators: • long & difficult labor • Cephalo-pelvic disproportion - big baby/small pelvis. • Shoulder dystocia: insert hand in vagina; Sweep arm that’s posterior across chest.  • McRobert’s Maneuver: Sharply flex legs on maternal abdomen; symphysis pubis rotates & sacrum is straightened. Widens pelvic opening. 50-60% cases resolved Nursing Interventions: • Monitor fetal/maternal status; provide O2/fluids • Clear & repeated descriptions of labor progress. • Careful assessment labor; assess maternal exhaustion. • Accept patient’s frustration/anxiety. • Prepare for poss.emer.delivery.

3. Psyche: • Anxiety/fear r/t pain leads to cycle of fear & anxiety. • ^ catecholamine release- leads to ^ physical distress. • Ineffective uterine activity; longer, more dysfunctional labor. Interventions: • Empower client; assure her she’s in control • Don’t force exams; explain procedures; privacy. • Childbirth education helpful. • Relaxation techniques: music, focal points, breathing exercises. • Give Pain relief as ordered; idea of epidural relaxes pt. • Be Pt. advocate.

4. Hypertonic Labor Patterns: • Contractions; normal duration - within 1 minute of each other; 5 or more in 10 minutes. • Painful but ineffective in dilating/effacing cervix. Prolonged latent phase. • Common w. Cervidil or Pitocin Maternal implications: Possible placental abruption, uterine rupture, infection, fever, difficult contractions. Maternal effects: exhaustion; loss of control. Fetal Implications: Hypoxia; Can cause ↓ uteroplacental blood flow; cause FHR decelerations d/t contx’s that are too strong/frequent. May lead to fetal distress/death. Interventions: stop infusion of oxytocin til uterine contx. return to normal. L lateral position, O2, rest, analgesics.

5. Hypotonic Labor Patterns: • More common than hyperstimulation. • Contraction of uterus w. insufficient force, ↓ frequency or both. • Often in primagravidas in active stage of labor; • caused by ^ sedation, early admin. of anesthesia, twins, polyhydramnios, overdistention of uterus [macrosomia] , CPD or malpresentaton of uterus. • Occurs > labor established. • Charac. by < 2-3 contractions in 10 min. Maternal Implications: Responds well to induction; 1st R/O CPD or malpresentation of fetus. Infection, exhaustion. Interventions lateral position; O2, IVF; Amniotomy [AROM]; may speed up labor. Start pitocin induction as per MD. Monitor mom VS; assess FHR w. fetal scalp electrode; assess contx’s with IUPC. Fetal Neonatal Implications: Infection; fetal distress; hypoxia; fetal death if hypotonic labor prolonged & not corrected.

6. Prolonged Labor: Labor > 24 hrs. Causes: CPD, malpresentations, uterine contraction Dysfunction, early anesthesia or macrosomia. Maternal Implications: Labor that doesn’t progress well: dehydration, exhaustion, rupture of uterus. Prolonged labor may contribute to maternal infection, hemorrhage. Fetal Implications: Can lead to neonatal infection; hypoxia; fetal death if not corrected. Management: Induce if able; possible C/S if induction fails.

7. Precipitous Labor: Last < 3 hrs. Cause: Lack of resistance of uterus/cervix to passage of fetus or intense uterine contractions. • Often leads to unattended birth by MD/midwife Maternal Implications: Hematomas, vaginal, cervical lacerations; uterine rupture, hemorrhage; infection. Fetal Implications: facial bruising; intracranial damage, nerve damage; hypoxia d/t quick del. Management: Promote fetal oxygenation; Stop pitocin induction; give O2 ; IV fluids; tocolytic drugs as ordered. Prepare for delivery. Note bulging of membranes, crowning, urge to bear down; monitor VS. For NON-COMPLICATED delivery: Nurse can deliver baby: support head/body; check cord is wrapped around baby’s neck; Suction mouth then nose. Deliver shoulders; Note time of delivery.

8. Premature Rupture of Membranes (PROM) • Spontaneous rupture @ least 1 hr. prior to onset of labor. Assoc. with: • sexual intercourse; AMA > 35; multiparity • Incompetent cervix; Infections [BV, GBS, gonorrhea]; • Low weight gain; • Delivery of pregnancy @ term. Vaginal exam not done [poss. intrauterine infection] – sterile speculum to estimate dilation. • Dx of PROM confirmed by amniotic fluid leaking Tests to determine pH: • 1. nitrazine paper - amniotic fluid - alkaline “blue”. • 2. microscopic exam - ferning - glass slide. • If L/S ratio indicates immature fetal lungs & mom/fetus are healthy, delivery delayed if no complications exist.

9. Maternal Implications: Chorioamnionitis; Endometritis [infection of inner lining of uterus]. Neonatal Implications: Chorioamnionitis; fetal tachycardia; risk of RDS w. premature birth; umbilical cord compression; fetal distress. Management: Temp & pulse q 4h. Bed rest w. BRP. For contractions: 1. Tocolytics [stop labor if not dilated> 4cm]. 2. AB for PROM > 12 h. 3. Pitocin given to induce labor 4. Steroids up to 34 wks + chorioamnionitis s/s: fever; ^ maternal & fetal HR; tender, painful uterus; foul odor of amniotic fluid.

10. Prolapsed Cord • Umbilical cord precedes fetal presenting part placing pressure on cord and diminishing blood flow to fetus • Bed rest recommended if engagement has not occurred and membranes have ruptured • Assess for nonreassuring fetal status • Bradycardia common; emergency C/S stat!

11. Preterm Labor: (PTL) Labor @ 20 - 36 wks. May be painless. Risk factors: PROM, multiple gestation, smoking, UTI; bacterial vaginosis; previous preterm delivery; stress; long working hours; short rest periods. S/S: contractions regular & cervical effacement 80% or dilation > 1cm. Contractions > than every 10 mins. persisting 1 hour or more; painless or painful. *Lower abdominal cramping with diarrhea, low back pain, menstrual like cramps, urinary frequency; vaginal discharge: blood, ROM.

12. Fetal/Neonatal Implications: Preterm labor leading cause of perinatal morbidity/mortality. Rate is increasing; Affects 8 -10 % births USA/year. Closer delivery is to term, ^ survival & lower morbidity d/t technologic advances. Premies have ^ morbidity. Health care costs > $3 billion/yr. [NICU] Interventions: PTL not associated with bleeding or leaking amniotic fluid can be stopped in 50% of patients with bed rest and hydration. Admit to L&D for monitoring of FHR, contx’s, & cervical changes.

13. Management Tocolytics to stop labor; can’t use if dilation > 4 cm. or with acute fetal distress. MgSO4 drug of choice. CNS depressant & smooth muscle relaxant Causes vasodilation and bronchodilation; relaxes uterus. Magnesium sulfate given over 24 - 48 hours Side Effects: decreased reflexes & respirations; decreased urine output. Foley catheter. Brethine, Terbutaline, Ritrodrine: Causes bronchodilation, ^ HR; take pulse before giving med. Steroids to mature lungs and antibiotics to mom Notify MD for HR 120 or ^.

14. New Testing: Fetal Fibronectin (fFN): Test for Preterm Delivery • To help predict PT delivery, some doctors screening for fetal fibronectin (fFN). • fFN: protein acts like “glue” attaching fetal sac to uterine lining. Present in vaginal secretions during 1st trimester & up to 22 wks. • indicates ^ risk of preterm delivery; suggests that "glue" is disintegrating ahead of schedule - alerts doctors to possibility of preterm delivery • After 22 wks, no longer detected until 1-3 wks before labor • Absence of fFN is reliable predictor that pregnancy will continue for at least another two weeks.

15. Ruptured Uterus– Tearing of intact uterus. Causes: weak incision, OB trauma, CPD, • mismanagement of oxytocin induction. Monitor for uterine hyperstimulation. In labor, old scar ruptures w .contractions; over distended uterus; multifetal presentation, malpresentation, external/internal version of fetus. Prevention best treatment. S/S silent. Close observation. Complete rupture: may c/o sudden, sharp, shooting abd.pain & state “something gave way”. • If in labor, contractions will stop & pain relieved. • May exhibit signs of hemorrhagic shock: hypotension, • tachypnea, pallor, cool, clammy skin.

16. Interventions: D/C oxytocin & give tocolytic med. Poss.emergency C/S, hysterectomy, blood transfusion. Monitor maternal VS, O2, IVF, antibiotics > delivery. After birth, assess for ^ bleeding & s/s shock. Fetal-Neonatal Implications: Fetal distress most reliable sign uterine rupture. Prolonged late decels & bradycardia. Do NBN VS; transfer to NICU. Neonatal death if not delivered in time.

17. Fetal Malposition: • Occiput aka posterior; back of fetal head directed towards back of maternal pelvis. • Common; 25% of time. • Labor (2nd stage) prolonged & mom c/o severe back pain. Interventions: counter-pressure on lower sacral area; heat/cold applications, knee press position. Attempts to rotate fetal head include lateral abdominal stroking, all fours position, squatting, pelvic rocking, lunges.

18. Fetal Malpresentation: (brow, face, breech, shoulder) Depends on degree of flexion. Breech most common (3-4%). Dx: abdominal palpation, vaginal exam; ultrasound. Interventions: Monitor FHR. External cephalic version may be attempted to turn breech to vertex presentation. Complications to neonate rare. Done > epidural to relax uterus. Breech Presentation: 3rd most common reason for C/S. Transverse lie: 1 in 300-400 deliveries. Reasons: grand multip, polyhydramnios, prematurity, fibroids, ovarian cysts, placenta previa, multiple preg., Main danger assoc.w. transverse lie is premature ROM & cord prolapse. Intervention: attempt version [MD]; C/S.

19. Multiple Gestation: Gestation of twins, triplets, more. Assoc.w. ^ maternal dysfunctions - hemorrhage. Higher risk for perinatal mortality r/t preterm birth or IUGR. Cord prolapse or placental separation w. 1st fetus may cause distress/hypoxia in 2nd. Pregnancy Complications: PTL & delivery, HTN, pre- eclampsia, placental abruption, anemia, hydramnios, UTI, hemorrhage, C/S.

20. Mulitple Fetuses: ^ risk for prematurity, IUGR, birth defects, significant discordance {> than 20% weight diff.}; vanishing twin [one gets reabsorbed]; cord entanglement; lowered blood/O2 supply to one/both infants. May result in death of one/both. Interventions: prevent PTL; Complete bedrest if needed Identical Twins: monozygotic; formed from one zygote; same sex; same genetic material. Division occurs by day 4-8; 2 amniotic sacs & 1 placenta. If division occurs > day 8, share amniotic sac & placenta; possible cord tangling & fetal death. If division occurs > day 12, cojoining occurs [siamese] Fraternal Twins: dizygotic; 2 separate zygotes; diff. genetic material; could be same sex or not. • 2 placentas & 2 sacs. • 70% of time [2 ova & 2 sperm]

21. Intrauterine Fetal Death {fetal demise} Cessation of fetal movement. 20 wks. or < “spontaneous AB” or miscarriage. > 20 wks. “Stillborn” Risk Factors: Maternal age {high & low}, multiple gestation, chronic HTN, preeclampsia, uncontrolled DM, viral/bacterial infections, congenital malformations (35%), IUGR, placental abruption, PROM. Confirm with ultrasound – no FHR. At prenatal visit - mom reports no FM. Induce w. cervidil/Pitocin; may take 1-2 days to deliver. Support parents; bereavement team/social worker involved; bereavement box contains photos/lock of hair etc. ID bands, footprint sheets.

22. Placenta Accreta: chorionic villi attach directly to myometrium of uterus. • ~ 1 in 7,000. • Hx previous C/S. • Abnormally firm attachment of placenta to uterine wall • Retained placenta may interfere w.uterine contractions necessary to control bleeding > delivery. • Severe bleeding results. • Major source of maternal morbidity/mortality. Treatment: Hysterectomy to control bleeding; Transfusions in > 50% of pts. Main OR w.experienced staff; Have blood products ready.

23. Cont. Risk Factors: # 1 placenta previa; 10% of all accretas. Rare; previous C/S’s, AMA >35; D&C‘s. Woman not prepared for poss. hysterectomy/loss of fertility. #1 Goal : control blood loss. Control of bleeding achieved w.hysterectomy. Uterine embolization may prevent hysterectomy. U.arteries cauterized. May save uterus. Maternal Complications : hemorrhage, infection. Definitive dx not poss.til delivery. May detect abnormal pulsations w. sono near bowel/bladder. Neonatal Complications: prematurity 2/3rds cases; 34-35wks.

24. Amniotic Fluid Embolism • AFE: obstetric emergency! • Amniotic fluid, fetal cells, lanugo, other debris enter maternal pulmonary circulatio; causes cardio-respiratory collapse. • Autopsy of maternal lungs reveals edema, alveolar hemorrhages, emboli [squamous cells, fat, bile, lanugo]. • In many cases, mixture between maternal/fetal materials is harmless. • Mixing causes series of physiological reactions resembling anaphylactic shock d/t contact with debris. • Blockage of maternal pulmonary vessels by emboli. Releases thromboplastin into circulation; leads to DIC

25. CLINICAL FINDINGS Mode of infusion • Tear in amniotic sac and opening into maternal vasculature thru uterine veins. • Amniotic fluid enters uterine/cervical veins d/t R rupture of amniotic sac & pressure gradient from uterus to veins [strong contractions] • Abrupt onset of hypotension, hypoxia, & coagulopathy • RARE; but once it occurs, common cause of maternal death. 1/ 20,000 deliveries • 25% of women die within 1 hour of onset

26. Risk Factors: • Multiparity; Age > 30; Large fetus • Intrauterine fetal death [saline to induce abortion] • Meconium in amniotic fluid; Strong uterine contractions Clinically: patient in either late stages of labor or immediately postpartum: 1st phase: • gasp for air • rapidly suffer seizure or cardiorespiratory arres 2nd phase: • Very often complicated by DIC • massive hemorrhage; death.

27. Management: • Circulatory support & O2 • Bronchodilators, vasodilators, volume expanders. • For DIC: plasma, cryoprecipitate, blood transfusion • With Cardiac arrest, C/S to improve newborn outcome. Prognosis: • Maternal death common; survivers may be neurologically impaired r/t hypoxia. • Infant may suffer residual neurological impairment. • ~ 70% of newborns survive.