Complications of Labor and Delivery

Dystocia - An abnormal, long, or difficult labor or delivery

COMPLICATIONS OF THE PSYCHE Etiology and Pathophysiology:

Hormones released in response to anxiety can cause DYSTOCIA Intense anxiety stimulates Sympathetic nervous system which releases catecholamines that lead to myometrial dysfunction. Norepinephrine and epinephrine lead to uncoordinated or increased uterine activity Nursing Care

Assess support available and be there for the patient Patient Teaching- breathing/relaxation Provide with non-pharmacological measures Keep informed Provide quiet calm environment

HYPERTONIC UTERINE CONTRACTIONS Most often occur in first-time mothers, Primigravidas

Contractions are ineffectual, erratic, uncoordinated, and involve only a portion of the uterus Increase in frequency of contractions, but intensity is decreased, do not bring about dilation and effacement of the cervix. Signs and Symptoms: 1. 2. PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain Dilation and effacement of the cervix does not occur.

3. 4. 5.

Prolonged latent phase. Stay at 2 - 3 cm. dont dilate as should Fetal distress occurs early uterine resting tone is high, decreasing placental perfusion. Anxious and discouraged

Treatment of Hypertonic Uterine Contractions Provide with COMFORT MEASURES

Warm shower; Mouth Care; Imagery; Music; Back rub Mild sedation Bedrest Hydration Tocolytics to reduce high uterine tone

HYPOTONIC UTERINE CONTRACTIONS UTERINE INERTIA Etiology and Pathophysiology:

Overstretching of the uterus --large baby, multiple babies, polyhydramnios, multiple parity Bowel or bladder distention preventing descent Excessive use of analgesia Signs and Symptoms of HYPOTONIC UTERINE INERTIA:

Weak contractions become mild Infrequent (every 10 15 minutes +) and brief, Can be easily indented with fingertip pressure at peak of contraction. Prolonged ACTIVE Phase Exhaustion of the mother Psychological trauma - frustrated

Therapeutic Interventions: 1. Ambulation getting up and walking will increase contractions

2. Nipple Stimulation causes release of endogenous Pitocin which can stimulate contractions 3. Enema--warmth of enema may stimulate contractions 4. AMNIOTOMY artificial rupture of the membranes Advantages of doing this before Pitocin

Contractions are more similar to those of spontaneous labor Usually no risk of rupture of the uterus Does not require as close surveillance Disadvantages of an Amniotomy

Delivery must occur Increase danger of prolapse of umbilical cord Compression and molding of the fetal head (caput) Nursing Care:

# 1-Check the fetal heart tones Assess color, odor, amount Provide with perineal care Monitor contractions Check temperature every 2 hours 5. Pitocin for augmentation of labor Use only if CPD is not present Give 20 units / 1000 cc. fluid and hang as a secondary infusion, never as primary

GOAL:

Achieve contractions every 2 - 3 minutes of good intensity with relaxation between Nursing Care:

Assess contractions--are they increasing but not tetanic Assess dilation and effacement Monitor vital signs and FHTs

Prolonged Labor Definition: A labor lasting more than 18-24 hours

Normally: Cervical dilation -- Primigravida 1.2 cm / hr. Multigravida 1.5 cm / hr Descent 1 cm. / hr in primigravida and 2 cm./ hr. in multigravida

PRECIPITIOUS LABOR OR DELIVERY Labor that last less than 3 hours Unexpected fast delivery Etiology

Lack of resistance of maternal tissue to passage of fetus Intense uterine contractions Small baby in a favorable position Complication:

If the baby delivers too fast, does not allow the cervix to dilate and efface which leads to cervical lacerations Uterine rupture Fetal hypoxia and fetal intracranial hemorrhage Rapid Delivery

Delivery Outside Normal Setting Everything is OUT OF CONTROL!

mom is frightened, angry, feels cheated Nursing Care:

Do NOT leave the mother alone Try to make the place clean, (dont break down table) Try to get the mother in control -- Have mom pant to decrease the urge to push Apply gentle pressure to the fetal head as it crowns to prevent rapid change in pressure in the fetal head which can cause subdural hemorrhage or dural tears. Deliver the baby BETWEEN contractions to control delivery Suction or hold babys head low and place on mom/s abdomen, tie off cord Allow to breast feed, Document!

Pelvic Dystocia Definition:

Pelvic Inlet or Outlet is not of sufficient size or proper shape to allow the baby to get through Etiology

Congenital defect Malnutrition -- Rickets Neoplasms Fracture / Trauma Signs and Symptoms:

Labor is arrested. Station does not decrease. Baby does not move down in the birth canal after long time in labor or with prolonged pushing. Therapeutic Interventions:

 cesarean delivery

Complications of the Passenger Malpositions:

Posterior position--usually mom complains of back pain Treatment:

Forceps -- low forceps or outlet forceps usually applied after crowning Vacuum extraction -- disk shaped cup placed over vertex of head and vacuum applied. Episiotomy - surgical incision to allow more room

Malpresentation -- brow, face, transverse, breech may allow to deliver vaginally with caution or Cesarean birth

Treatment:

May allow to deliver with caution or C-birth Version -- alteration of fetal position by abdominal or intrauterine manipulation

Cephalopelvic Disproportion

Large baby or small pelvis Usually diagnosed when there is an arrest in descent Station remains the same Treatment:

Cesarean Delivery

Multiple Fetus

may be delivered by cesarean birth

 CESAREAN DELIVERY OPERATIVE PROCEDURE IN WHICH THE FETUS IS DELIVERED THROUGH AN INCISION IN THE ABDOMEN REMEMBER -- IT IS A BIRTH ! Mom may feel less than normal, so may need support May have option of a VBAC the next time

Premature Rupture of the Membranes / PROM Definition:

Spontaneous rupture of the membranes Etiology - Incompetent cervix

Infections

Fetal abnormalities - Sexual Intercourse Major risk - ascending intrauterine infection Other risk -- Precipitation of labor Treatment and Nursing Care:

Wait and watch, bedrest, no intercourse Betamethasone / Celestone -- provides stressor to the lungs of the fetus to stimulate production of surfactant Assess time membranes ruptures and if labor started Check temperature frequently Describe character of amniotic fluid Check WBC Provide psychological support

Preterm Labor Definition: Labor that occurs after 20 weeks but before 37 weeks Etiology: urinary tract infections Premature rupture of membranes Goal -- STOP THE LABOR ! suppress uterine activity

Therapeutic Interventions: Drug Therapy / Tocolytics

Uses: Stop or arrest labor Criteria for use, dont give if:

Patient is in Active labor, cervix has dilated to 4 cm. or more Presence of Severe Pre-eclampsia Fetal complications / Fetal demise Hemorrhage is present Ruptured membranes Examples:

Yutopar (ritodrine) or Brethine (terbutaline sulfate)

SIDE EFFECTS or WARNING SIGNS: Palpitations Tachycardia - pulse ~120 Tremors, nervousness, restlessness Headache, severe dizziness

 Hyperglycemia

TOXIC EFFECTS - PULMONARY EDEMA

- rales, crackles, dyspnea - Must perform chest assessment with nursing assessment every shift and chart lung sounds. Nursing Care: Stop the medication Start oxygen Give ANTIDOTE: INDERAL Patient Teaching: Teach how to take medication -- on time Teach patient to check pulse, call Dr. if > 120 140 (dehydration increases contractions) Teach to assess fetal movement daily, kick counts Drink 8-10 glasses of water per day Monitor uterine activity -- Home monitoring -- call dr. if has contractions Decrease activity Lie on side Keep bladder empty

Ruptured Uterus Spontaneous or traumatic rupture of the uterus Etiology:

Rupture of a previous C-birth scar Prolonged labor

 Injudicious use of Pitocin -- overstimulation Excessive manual pressure applied to the fundus during delivery Signs and Symptoms:

Sudden sharp abdominal pain, abdominal tenderness Cessation of contractions Absence of fetal heart tones Shock Therapeutic Interventions:

Deliver the baby ! / Cesarean Delivery

Prolapse of the Umbilical Cord Definition: Prolapse of the umbilical cord thorough the cervical canal along side of the presenting part Etiology: Occurs anytime the inlet is not occluded. Fetus is not well engaged GOAL:

RELIEVE THE PRESSURE ON THE CORD SUPPORT MOTHER AND THE FAMILY NURSING CARE / Therapeutic Interventions:

**Get the pressure off the Cord --place in trendelenberg or knee-chest position OR elevate part with sterile gloved hand Palpate FHTs, NEVER ATTEMPT TO REPLACE CORD! Give O2 per mask at 10 Liters Cover exposed cord with sterile wet gauze Stay with the patient and offer support

Amniotic Fluid Embolism Escape of amniotic fluid into the maternal circulation

usually enters maternal circulation through open sinus at placental site Usually fatal to the Mother

amniotic fluid contains debris, lanugo, vernix, meconium, etc. Signs and Symptoms:

dyspnea chest pain cyanosis shock Therapeutic Interventions:

Deliver the baby Provide cardiovascular and respiratory support to Mom

Premature Labor

labor that begins after 20 weeks gestation and before 37 weeks gestation.

Causes of Preterm Labor: 1. PROM 2. Preeclampsia 3. Hydramnios 4. Placenta previa 5. Abruptio placentae 6. Incompetent cervix 7. Trauma

8. Uterine structural anomalies 9. Multiple gestation 10. Intrauterine infection (chorioamnionitis) 11. Congenital adrenal hyperplasia 12. Fetal death 13. Maternal factors, such as stress (physical and emotional) 14. Urinary tract Infection 15. Dehydration