COMPLICATIONS OF LABOR

I. PRETERM LABOR

A. DESCRIPTION: Labor that occurs after the 20th week and before 37th week of gestation
B. RISK FACTORS
1. Maternal Factors
a. Maternal infection (leading cause), illness or disease (renal/cardiovascular),diabetes mellitus
b. Premature rupture of membranes (PROM)
c. Bleeding
d. Uterine abnormalities/overdistention, incompetent cervix
e. Previous preterm labor, spontaneous or induced abortion, preeclampsia, short interval
(less than 1 year) between pregnancies
f. Trauma, poor nutrition probably due to low socioeconomic status, no prenatal care,
lack of child experience
g. Extremes of age, decreased weight (less than 100 lb.) and height (less than 5 ft)
h, Lack of rest/excessive
i. Smoking
j. Extreme emotional stress
2. Fetal Factors
a. Multiple pregnancy
b. Infections
c Polyhydramnios
d. Congenital adrenal hyperplasia
e. Fetal malformation
3. Placenta Factors
a. Placental separation
b. Placenta disorder
4. Unknown Causes
C. COMPLICATIONS

1. Prematurity
2. Fetal death
3. Small-for-gestational age / IUGR
4. Increase perinatal

D. TREATMENT: Hospitalization  prevent premature delivery

1. Bed rest on left lateral recumbent
2. Adequate HYDRATION: oral & parenteral
3. Monitoring
a. Uterine contractions and irritability q1-2 hrs (determine increasing or decreasing contractions)
b. Vital signs, as major drugs employed can alter them
c. Intake and output
d. Signs of Infection
e. Cardiac and respiratory status and distress signs
f. Cervical consistency, dilatation, and effacement
g. Fetal well-being
h. Early signs of edema: pulmonary edema is a possible complication of ritodrine use

4. Promotion of physical and emotional comfort: keep client informed of progress.

5. Administration of Tocolytics to arrest labor by causing relaxation of the uterus, examples:
Magnesium sulfate, Terbutaline and ritodrine
a. Contraindications to arresting premature labor
. Advanced pregnancy
. Ruptured bag of waters
. Maternal diseases like bleeding complications, PIH, cardiovascular disease
. Fetal distress
. Presence of fetal problems like Rh isoimmunization
6. Administration of cortiscosteroids like betamethasone (Celestone) to enhance maturation
Of fetal lungs by stimulating the production of surfactant when there are contraindications to
Attempts to arrest preterm labor.
 a. Administer ordered drugs according to protocol.
b. Assess effects of drugs on labor and fetus
c. Monitor for side effect of the drugs

E. DISCHARGE: Once contractions have stopped, and maternal and fetal conditions stabilized
The client is discharged.

Health Teachings: should include measures to prevent recurrence of premature labor:

1. Maintain bed rest, left-lateral preferred.
2. Well-balanced diet: high in iron, vitamins, and important minerals
3. Continuation of oral medications (Yutopar) at home
4.Frequent prenatal visit every week for the duration of the remaining weeks
5. Activity/Lifestyle evaluated and restricted as necessary
6. Illnesses: chronic – monitored; acute – Treated STAT
7. Provide client teaching: symptoms of preterm labor and prompt reporting to the physician
When present
F. OTHER INTERVENTIONS: Provision of psychological support and encouragement

II. PERCIPITATE LABOR

A. DESCRIPTION: Short labor that lasts for 2 to 3 hours or less

B. RISK FACTORS
1. Multiparity – most common/ important factor
2. Trauma
3. Large pelvis and lax soft tissues
4. Small fetus
5. Labor induction by oxytocin and rupture of membranes
6. Severe emotional stress
C. COMPLICATIONS
1. MATERNAL
a. Laceration
b. Hemorrhage
 c. Infection
d. Uterine rupture if birth canal is not readily distensible
e. Hypotonic contractions  hemorrhage

2. Fetal
a. Hypoxia, anoxia
b. Sepsis
c. Intracranial hemorrhage

3. TREATMENT
1. Episiotomy
2. Delivery

E. ASSESSMENT FINDINGS

1. Tetanic- like contractions

2. Rapid labor and delivery
3. Signs and symptoms of impending delivery
a. Desire to push
b. Strong contractions
c. Ruptured membranes
d. Heavy bloody show
e. Bulging rectum
f. Severe anxiety

F. NURSING IMPLEMENTATION
1. Never leave client
2. Monitor FHT q15 min. to detect distress from fetal hypoxia secondary to tetanic contractions
3. Provide emotional support.
a. Reassure that you will stay
b. Explain precipitate labor in simple terms.
c. Inform the client of what is happening.
d. Provide care until physician/ help arrives.
 e. Assist client in retaining a sense of control over what is happening
4. Assist with delivery.
a. Never hold the baby back.
b. Put on sterile gloves if available, and if there is still time.
c. Have client pant and not push.
d. Rupture the membranes when head crowns.
e. Gently slip the cord over the head, with free hand if the cord is draped around the neck.
f. Use gentle pressure to fetal head upwards toward the vagina to prevent damage/injury
to fetal head and vaginal lacerations.
g. Deliver head in- between contractions.
h. Shoulders are usually born spontaneously after external rotation; if not, use gentle, downward pressure
to move anterior shoulder under symphysis pubis and then use upward pressure for the delivery of
posterior shoulder.
i. Right after the head is delivered and before the shoulders is out, suction the mouth and nose using bulb
syringe, if available; if not, use towel to wipe blood and mucus from mouth and nose
j. Support the fetal body during expulsion.
k. Care for the cord:
. If materials are available, clamp cord in two places and cut between with clean knife or scissors.
. If there is no available instrument for cord clamping and cutting, just double tie using the cleanest
Possible piece of cloth or string (e.g., a clean handkerchief) ensuring that there is no pulsation
between the two ties to prevent transfusing newborn blood to the outside which will lead to
neonatal hemorrhage and shock.
l. Allow placenta to separate naturally. Wrap placenta, cord, and baby together. Have the fetal side near
the newborn.
m. Place infant on mother’s abdomen, or better still encourage mother to breastfeed to induce uterine
contractions and for reassurance that all is well.
n. Institute measures as prescribed in the third and fourth stage of labor.
o. Handle delivery gently to prevent injury to mother and baby.

III. DYSTOCIA
A. DESCRIPTION: Prolonged difficult labor and/ or delivery because of problems with the factors in labor (4 P’s)
B. RISK FACTORS
1. Faults of the passengers
 a. Abnormal position, persistent occiput posterior (failure of the vertex to rotate)
b. Mal presentations (shoulder, face, brow, breech)
c. Hydrocephaly
d. Large fetus (over 4000 grams)
e. Abnormal lie (transverse)
f. Multiple pregnancy.

2. Faults of the Passages

a. Cervical inertia
b. Contracted pelvis
c. Cephalopelvic disproportion (CPD)
d. Non-gynecoid pelvis
e . Cervical scar tissue from previous surgery

3. Faults of the Primary Power

a. Hypertonic uterine inertia
b. Hypotonic uterine inertia

4. Faults of the Person/Client: Poor psychosocial responses which are influenced by the following factors:
a. Education and preparation
b. Previous experiences
c. Readiness
d. Support system
e. Maternal position
f. Race and culture
g. Environment
h. Socioeconomic status

C. COMPLICATIONS

1. Maternal exhaustion and dehydration

2. Infection
3. Traumatic operative births
 4. Fetal distress
5. Birth injuries
6. Perinatal mortality

D. TREATMENT
1. Bed rest
2. Sedation for hypertonicity
3. Stimulation with oxytocin for hypotonicity
4. Cesarean section
5. Forceps as indicated

E. DIAGNOSIS
1. Vaginal examination
2. Leopold’s maneuvers
3. Pelvimetry
4. Ultrasonography
5. Diagnosis of type of dystocia

F. NURSING IMPLEMENTATION

1. Prepare client for/assist in various diagnostic examinations.

2. Promote rest and comfort; quiet, darken room.
3. Proper position for comfort: lateral position is comforting.
4. Monitor:
a. Labor: uterine contractions, cervix
b. Fetal well-being: FHT, movement, passage of meconium
5. Give reassurance and support.
6. Administer oxytocin as ordered for hypotonic uterine inertia to augment labor.
a. The patient should not be left alone. The nurse monitors the rate of flow, the maternal
response in terms of uterine contraction changes and cervical dilatation/effacement
changes. Physician must be present within the unit or within the floor and available
throughout the procedure.
Safety Alert: Oxytocic drugs in labor induction and augmentation may cause uterine
 Hypertonicity and lead to serious complications as uterine Rupture, abruption placenta,
and fetal distress. The woman with oxytocin drip should not be left alone!
b. Client must be in true labor – cervix at least 3 cm.
c. No mechanical obstruction or uterine over distention or multiple fetuses
d. With indications for oxytocin: No history of CS (rupture), Fetus in good condition,
client under 35 years old and less than para 5

Hypotonic Uterine Inertia Hypertonic Uterine Inertia

Onset: Late onset; usually in the active Onset: Early onset; usually as early as
phase the latent phase
Contractions: Weak, painless Contractions: Strong, painful
Tension not synchronous Uncoordinated, increased contractions
but ineffective in bringing about further
dilatation
Causes: Over distention, advanced Causes: Primigravidity, young age,
age, increased parity, contractures, injudicious use of oxytocin
fetal mal position, analgesia/anesthesia
Treatment: Enema, walking if not Treatment: Sedation
contraindicated; amniotomy, oxytocin

e. Monitor VS, drip rate of IV oxytocin carefully and frequently. Maternal hypotension and hypertension
can result from oxytocin drip. BP is therefore the single, most important vital sign to be monitored.
f. Assist with delivery: after failed trial labor (usually 6 hours)
. Vaginal delivery
. Cesarean section
g. After delivery, observe mother and infant for signs of injuries and signs of difficult interaction related
to/resulting from difficult labor. Promote bonding.

IV. PREMATURE RUPTURE OF MEMBRANES (PROM)

A. DESCRIPTION: Rupture of the membrane before term/labor; unconnected with labor
B. ASSESMENT FINDINGS
1. Maternal report of passage of fluid per vagina
2. Determination of alkaline amniotic fluid and not acidic urine or vaginal discharge
C. DIAGNOSIS
1. Nitrazine test: change in the color of nitrazine paper from yellow (acidic vaginal Ph = 4-6)
To blue color because of neutral to slightly alkaline amniotic fluid (pH = 7-7.5)
2. Ferning test: amniotic fluid, high in sodium content, will assume a ferning pattern when dried on the slide
3. Sterile speculum examination: direct visualization of fluid from cervical on is the
most reliable diagnosis of PROM

D. COMPLICATIONS
1. Maternal infection/chorioamnionitis – most common
2. Cord prolapse
3. Pre-matured labor

E. NURSING IMPLEMENTATION
1. Maintain bed rest. Do not allow ambulation to prevent prolapse of the umbilical cord.
2. Calculate gestational age.
3. Monitor maternal vitals signs and fetal well-being.
4. Observe and record the character, amount, color , and odor of amniotic fluid.
5. Be alert for early signs of infections: fever, chills, malaise, and signs of labor onset
6. Monitor for signs of prolapsed cord =.
7. Provide appropriate treatment as ordered:
a. If there are signs of infection: antibiotics and immediate delivery.
b. If without signs of infection, induction of labor delayed, provided fetus is healthy.
8. Provide psychological support:
a. Explain the procedures and findings
b. Support client and family
c. Inform of progress
d. Prepare client and family for early interruption of pregnancy as indicated

V. UTERINE RUPTURE
A. DESCRIPTION: Rupture of the uterus because of the stress of labor with extrusion of uterine contents
 into the abdominal cavity
B. RISK FACTORS

1. Previous CS scar – most common cause/ contributory factor

2. Improper use of oxytocin
3. Over distention of the uterus
4. Strong contractions with non-progressive labor
5. Abnormal presentation
6. Trauma
7. Injudicious Obstetrics: application of forceps when the cervix is not yet fully dilated:
Second stage of labor fundal pressure; forced delivery of fetus with abnormality
(hydrocephaly)
8. Ill-advised podalic version

C. ASSESSMENT FINDINGS
1. Sudden acute abdominal pain and tenderness
2. Cessation of uterine contractions and FHT
3. Presenting part no longer felt through the cervix
4. A feeling in the mother that something happened inside her
5. Signs of external bleeding; signs of shock
6. Presence of predisposing factors

D. COMPLICATIONS
1. Hemorrhage or shock
2. Maternal and fetal Mortality: considered the most common complication of labor that
May result to maternal and fetal deaths
3. Infections from traumatized tissues

E. TREATMENT
1. Laparotomy to deliver the fetus
2. Hysterectomy for complete rupture (although in most cases, the uterus may be satured and left in)
3. Blood, plasma, and IV fluid replacement
4. Antibiotics
F. NURSING IMPLEMENTATION
1. Stay with client; call assistance.
2. Promptly implement supportive measures.
a. Positioning: shock position
b. Provision of warmth
c.Prompt IV infusion: D5LRS

3. Notify physician; inform support person.

4. Prepare for immediate surgery.
5. Provide psychology support.

VI. FETAL DISTRESS

A. DESCRIPTION: Fetal condition from fetal hypoxia

B. RISK FACTORS

1. Dystocia
2. Cord coil, cord compression
3. Improper use of oxytocin, analgesia/anesthesia
4. Diabetes mellitus, cardiac disease , and other co-existing conditions in the mother
5. Bleeding complications in the third trimester like placenta previa and abruption placenta
6. Pregnancy induced hypertension (PIH)
7. Supine hypotensive syndrome

C. ASSESSMENT FINDINGS TRIAD SYMTOMS

1. FHT above 160 or below 120 per minute

2. Meconium-stained amniotic fluid in a non-breech presentation
3. Fetal hypermobility/hyperactivity
D. NURSING IMPLEMENTATION

1. Reposition mother to left lateral recumbent (LLR). This relieves pressure on inferior vena cava (IVC), thereby,
increasing venous return resulting in increased perfusion of placenta and fetus.
2. Stop the oxytocin drip if being infused.
3. Administer oxygen per mask at 6 to 7 liters per minute.
4. Correct hypotension.
a. Elevate legs.
b. Increased IV rate (increase hydration) provided the IV fluid is plain and with no oxytocin.
c. Turn mother to her left if it is a case of vena caval syndrome.
5. Monitor FHT continuously.
6. Notify the physician.
7. Prepare for emergency CS if indicated.

VII. VENA CAVAL SYNDROME/ SUPINE HYPOTENSION SYNDROME

A. DESCRIPTION: Partial occlusion of the vena cava from the pressure of the pregnant uterus causing shock-like
symptoms

The pressure of the enlarged uterus on the inferior vena cava and aorta especially during contractions causes a
reduction in the blood flow up to the heart  reduced cardiac output  SUPINE HYPOTENSIVE SYNDROME 
decreased blood flow to feto-placental unit  fetal distress.

B. RISK FACTORS

1. Conditions where the uterus is extra large:

a. Multiple pregnancy
b. Polyhydramnios
c. Diabetes Mellitus

2. Obesity
 3. Prolonged supine position

C. NURSING IMPLEMENTATION

1. Prevention: LLR or left lateral recumbent for women in labor; avoid the supine position.

2. Management: repose mother to left stat in case of vena cava syndrome or use a wedge-shaped pillow
under the women’s right hip to shift the weight of the uterus/fetus of the woman’s aorta and inferior vena cava;
monitor fetal heart tones frequently.

VIII. AMNIOTIC FLUID EMBOLISM

A. DESCRIPTION: The escape of amniotic fluid into maternal circulations through the placental site and into the
pulmonary arterioles

B. RISK FACTORS

1. Premature or normal rupture of membranes. The risk of having amniotic fluid embolism starts from the
moment the bag of water ruptures.

2. Abruptio placenta

3. Difficult labor (hypertonic intense uterine contractions)

C. INCIDENCE: Rare but usually fatal; mortality in the first hour in 25% of pregnant women with amniotic fluid
embolism.

D. PROGNOSIS: Usually fatal for both mother and baby

E. ASSESSMENT FINDINGS

1. Maternal Respiratory Distress

a. Acute dyspnea
 b. Cyanosis
c. Sudden chest pains
d. Pulmonary shock and edema

2. Circulatory collapse: signs of shock

3. Secondary: uncontrolled bleeding from disseminated intravascular coagulation (DIC)

F. TREATMENT: Cardiorespiratory support

1. Oxygenation stat

2. Improve hydration.
a. IV fluid and plasma
b. Whole blood, fibrinogen transfusion
c. Monitor fluids, I&O

3. Digitalis for failing cardiac function

4. Heparin as ordered; be ready with antidote protamine sulfate.

5. Antibiotics

6. Delivery: forceps (if cervix is fully dilated) or vaginal (if cervix is open and dilating well)

7. Continued monitoring of mother and fetus

G. NURSING IMPLEMENTATION

1. Institute measures to support life.

a. Place on shock position as indicated.
b. Oxygenate promptly.
c. Maintain and monitor fluids and blood transfusion.
 d. Provide warmth.
e. Administer ordered drugs.
2. Inform family of the woman’s condition; provide support.
3. Transfer to ICU when stabilized for close monitoring and intensive care.

OPERATIVE OBSTETRICS

I. INDUCTION OF LABOR

A. DESCRIPTION: Deliberate initiation of labor or uterine contractions before spontaneous onset

B. INDICATIONS

1. Diabetic mother – may be by 36 to 37 weeks

2. Postmaturity; placental insufficiency
3. Increasing symptoms of toxemia (PIH)
4. Severe erythroblastosis fetalis; prolonged PROM
5. Maternal or physician’s convenience (not a valid indication)

C. METHODS OF INDUCTION

1. Administration of pituitary hormones or synthetic substitute: PITOCIN – most commonly used

a. Initiates and sustains uterine contractions
b. Strict monitoring: maternal and fetal VS and uterine contractions - length, intensity, and
frequency
2. Artificial rupture of membranes (amniotomy) causes stronger contractions because the hard fetal head
exerts greater pressure on the cervix; performed by a physician.
a. Prepare amniotone, pair of sterile gloves, and lubricant.
b. Explain procedure to client/couple.
c. Provide psychological support.
d. Check FHT immediately after the BOW is ruptured.
3. Stripping the Membranes: separating the membranes from the lower uterine segment without
rupturing the membranes  membranes and amniotic fluid now act as a wedge to effect cervical
 Dilatation.

D. PREREQUISITES FOR SUCCESSFUL INDUCTION

1. Mature fetus; mother at, or near term

2. No CPD
3. Soft and easily pliable cervix with moderate amount of dilatation and effacement
4. Fetal head fixed in inlet
5. No contraindications for the use of oxytocin like CS scar, hypertonic contractions, CPD, fetal
Distress and placenta previa.

E. NURSING IMPLEMENTATION

1 Explain plan of induction and all procedures as they are being performed to minimize anxiety;
Reassure of fetal well-being during induction.

2. Close Monitoring of Mother and Fetus

a. Rationale: pituitary (posterior) extract is very powerful and can cause violent uterine contractions.

3. Careful Administration of Oxytocin

10 IU of Pitocin is added to 1 liter of 5% dextrose in water and piggybacked to the main line (the major IV
line without medication).

4. Stop the infusion if any of these conditions exists:

a. FHT is greater than 170 bpm or less than 120 bpm; late decelerations; meconium passage in
cephalic presentation.
b. Maternal hypotension
c. Strong, sustained contractions

5. Evaluate Success of Induction: 3 contractions in 10 minutes present with about 50 mmHg pressure on
the average in intensity

6. Induction requires that the physician is in the area while the patient is receiving treatment.
 7. In the event that fetal distress develops, do the following:
a. Stop the oxytocin infusion; run at faster rate the IV solution without oxytocin.
b. Turn client to the left side.
c. Administer oxygen per mask.
d. Refer to the physician.

II. FORCEPS DELIVERY

A. DESCRIPTION: Delivery of the baby using obstetrical instruments – the forceps which consist of a blade,
shank, handle, and a lock

B. INDICATOR/RISK FACTORS

1. Fetal Factors
a. Second stage of labor fetal distress
b. Abnormal presentation or arrested descent
c. Preterm labor to protect fetal head from injuries
2. Maternal Factors
a. To shorten the second stage of labor
b. Ineffective expulsive effort/poor progress
c. Exhaustion
d. Medical diseases like cardiac disease

C. CRITERIA/PREREQUISITES

1. Full dilation of the cervix

2. Ruptured bag of water

3. Engaged head

4. Empty bowel and bladder

 5. No CPD

6. Episiotomy

7. Anesthesia

D. TYPES

1. Low/Outlet Forceps: fetal head on perineal floor

2. Midforceps: fetal head at the level of the ischial spines.

E. COMPLICATIONS/PROGNOSIS

1. Maternal
a. Lacerations
b. Hemorrhage
c. Uterine rupture
d. Uterine prolapse
e. Cystocele
d. Rectocele

2. Fetal
a. Facial paralysis (Bell’s palsy)
b. Increased perinatal morbidity and mortality
c. Intracranial hemorrhage
d. Brain damage
e. Skull fracture
f. Tissue trauma
g. Cord compression

F. NURSING IMPLEMENTATION
 1. Prepare client and family.
2. Provide psychological support to ally/decrease anxiety.
3. Monitor FHT continuously.
4. Assess mother and infant for complications.

III. CESAREAN SECTION

A. DESCRIPTION: Delivery via an abdominal incision.

B. INDICATIONS

1. CPD: leading cause of primary cesarean section

2. Previous CS: leading cause of secondary cesarean section

3. Contracted pelvis

4. Fetal distress

5. Dystocia

6. Diabetes mellitus; PIH

7. Placenta previa; abruptio placenta

8. Postmaturity

9. Rh incompatibility
10. Abnormal fetal positions and presentations

11. Cord prolapse

12. Fetal abnormalities, like hydrocephalus

 13. Pelvic tumors

14. Vaginal infections: Herpes

C. NURSING IMPLEMENTATION

1. Pre-operative: follow regular preparation for an abdominal/pelvic surgery

2. Post-operative
a. Ensure a patent airway and prevent respiratory obstruction; equip the postpartal recovery room with suction
and oxygen. If under general anesthesia, position patient on her side to promote drainage of secretions; turn
and assist with coughing and deep breathing q2 hours.

b. In the recovery room, monitor VS q5 min. Until stable; q5 min. for 1hr.; and q30 min. until discharged
to the postpartal floor.

c. Monitor uterine fundus gently to ensure that it is firm. The fundus may be palpated by placing a hand
to support the incision, but do not tamper with the abdominal dressing.

d. Check the dressing and perineal pad q15 min. for at least 1 hr. to evaluate lochial amount accurately, do
pad count or weigh perineal pads, if feasible

e. Monitor I&O. Observe urine for bloody tinge which is a danger sign of trauma to the bladder during
surgery.

f. Maintain fluid and electrolyte balance.

 Clear liquids after passage of flatus (requirement to oral intake)
 Early resumptions of solids

g. Provide assistants during mothers/father infant interactions.

 Provide emotional support
 Promote bonding
  Be present during entire initial breast feeding time.

h. Administer drugs as ordered.

 Oxytocics: to ensure a firm fundus
 Analgesics: to provide relief of postoperative pain
 Antibiotics: to prevent puerperal sepsis
i. Encourage early exercises following cesarean sections.
j. Assess for symptoms of complications: hemorrhage, infection, and leg thrombophlebitis.
 Assist in regular turning/repositioning in bed
 Passive, then active leg exercises
 Assess for danger signs: local redness (rubor), warm to touch ( calor), swelling (tumor) and pain (dolor).
Validate by eliciting the Homan’s signs: Calf pain upon dorsiflexion of the leg.

IV. ANALGESIA AND ANESTHESIA IN LABOR

A. ANALGESIA: The relief of pain and pain perception; analgesia can be provided by a variety of techniques
including drugs. Analgesics are drugs that relieve pain and pain perception.

1. Narcotics
a. Strong analgesic drugs that produce sedation and relaxation

Exercises Following Cesarean Section (Brayshaw, 1999)

Exercise Time to Start Purpose

 Foot & leg exercises As soon as possible, To improve circulation,
especially after epidural reduce edema, and
anesthesia, as peripheral prevent deep vein
circulation is sluggish  thrombosis (DVT)
high-risk for DVT
Abdominal tightening, Can be practiced gently To ease backache and
pelvic tilting, knee rolling after 24 hours flatulence; the abdominal
tightening tones the deep
transverse abdominal
muscles which are the
main support of the
spine, will help prevent
backache in the future
(Hodges & Richarson,
1995)
Pelvic floor exercise, curl- After 4 to 5 days when To prevent stress
ups, hip hitching woman is more incontinence
comfortable
Strenuous keep-fit 10 to 12 weeks after To keep fit and help
exercises, aerobics, surgery and only after regain strength
competitive sports ensuring that pelvic floor
muscles are functioning
effectively
Safety Alert: The exercises that should never be performed are double-leg-lifts and sit-ups. Lifting should be avoided; if
Inevitable, keep the object as light as possible and close to the body, bend knees, and straighten back.

b. Depress newborn’s respiration

c. Given in active labor (When cervix is about 4 to 6 cm)
d. Examples:
Pethidine in England (Demerol/ Meperidine in the USA) side effect: vomiting
 possible aspiration. The drug causes reduced gastric motility  gastric
Contents remain the stomach  vomiting  risk of aspiration of acid stomach
Contents; the concern is greater if anesthesia is required in an obstetric emergency
 (Reynolds,1993).

2. Tranquilizers
a. Produce sedation and relaxation
b May cause excitement when there is pain
c. Given with narcotics for potentiating effect
(little analgesic effect when given alone)
d. Examples:
. Phenergan (Promethazine HCI)
. Valium (Diazepam)
. Sparine (Promazine HCI)

3. Sedatives
a. Produce sedation
b. May depress fetus
c. Examples:
. Seconal (Secobarbital sodium)
. Nembutal (Pentobarbital sodium)

B. ANESTHESIA: The absence of sensation, implies ‘freedom from pain’ (Bevis,1999);

Anesthetics are agents that produce insensitivity to pain or sensation; produce local
General loss of sensation

1. General Anesthesia: the loss of sensation from the entire body, secondary to the loss
Of consciousness produced by intravenous or inhalation anesthetic agents

a. Unconsciousness prevents the brain from interpreting neural impulses into conscious
awareness but it does not prevent the transmission of neural impulses of pain and
other sensations. In general anesthesia, the need for other factors as amnesia,
analgesia, and muscle relaxation – through the administration of other drugs – is
considered to add to the unconsciousness factor (Littleton & Engebretson, 2006)
b. Needed when there is an indication for rapid induction or fetal manipulations.
c. Not commonly used in obstetrics because it causes uterine atony. The woman who received
 general inhalation anesthesia should be observed for hemorrhage in the postpartum period
and should have frequent monitoring of her uterine fundus.
d. May depress fetus
e. Induces sleep, vomiting; may cause aspiration

2. Regional: regional techniques alone or in combination with other techniques are commonly
Used to provide analgesia for labor pain (Ellis. 1997).
History of Analgesia/Anesthesia in childbirth
Mid-19th Century Advent of anesthesia in great Britain
and the U.S (Cohen, 1996)
Dr. James Young Simpson credited
with being an early user of ether, and
then chloroform in obstetrical practice.
1849 Committee on Obstetrics of the
American Medical Association
recommended the use of anesthesia in
obstetrics, stating that pain relief in
labor was justified (Morrission et al.,
1996)
Rabbi Abraham De Sola, Canada’s first
rabbi, clarified the meaning of Genesis
3:16 (thought to imply that God had
decreed that in pain would woman
bring forth children) in a published
article concluding that the use of
anesthetics for pain relief in labor was
not opposed by scripture (Cohen,
1996)
1853 Chloroform was administered to Queen
Victoria of England (head of the church
of England) by Dr. John Snow for her
9th child Prince Leopold which led to
 the end religious controversy
surrounding Genesis 3:16 (Kyle &
Shampoo, 1997; Cohen, 1996;
Morrission et al., 1996 Ball, 1996.)
1862 Chloroform and ether were in general
use for anesthesia
In obstetrics practice (Morrission et
al., 1996)
Development of parenteral OPIODS,
first MORPHINE and then DEMEROL,
and use of both parenteral and
inhalation
Anesthesia (Morrission et al.,
1996).
Early 20th century Increased use of twilight sleep: adding
scopolamine to morphine with resultant
Analgesia, amnesia, and maternal
restlessness  high incidence of
neonatal respiratory depression
(Morrission et al., 1996).
1940s-1950s Natural childbirth movement began
became apparent in the U.S in 1960s
with the induction of Lamaze method
(Sandelowski, 1984).
1951 Dr. Fernand Lamaze, a French
obstetrician, introduced
Lamaze method in France in 1951
after attending a
Conference in Russia on
psychoprophylaxis . the terms
psychoprophylactic (mind prevention)
and Lamaze are used interchangeably
(Olds et al., 1988).
 First half of 20th century Technique of epidural anesthesia was
known; use in
Obstetrics was limited. Refinement
of the technique and improvement in
the available equipment and drugs led
to an increased use of epidural
anesthesia (Morrission et al.,1996).

a. Causes loss of sensation from a large area of the body

b. Relieves uterine and perineal pain
c. Possible but rare complications with regional analgesia and anesthesia
. Trauma to nerve root or spinal cord is possible but extremely rare and resolves within weeks to several
Months (Conception, 1996). Danger sign of damage: paresthesias or hyperalgesia in the area innervated by that
Root
. Postdural puncture headache: occurs when the dura mater of the spinal cord is punctured. The punctured can be
Deliberate (introduction of opioids or spinal anesthesia) or accidental (epidural anesthesia); causes severe pain
when client is in upright, sitting, or standing position, and relieved or minimal when client assumes a horizontal position
(Chadwick & Ross, 1992); onset usually within 5 days and not responsive to minor analgesics. Treatment: hydration (to
replace lost CFS), analgesic (may provide some relief), and oral or IV c a f f e I n e (to cause c e r e b r a l
vasoconstriction)

. Hematoma in the spinal canal: rare but can cause spinal cord compression or ischemia (Drasner & Swisher,1996); a
reason why spinal and epidural anesthesia methods are contraindicated in the presence of severe coagulopathies
. D i m i n i s h m e n t of u t e r I n e contractions is women receiving epidural analgesia with epinephrine-
containing solutions (Chantigian and Chantigian, 1996)

. Increased duration of the second stage of labor is common. In the presence of epidural analgesia, prolonged
second stage of labor is defined as more than 3 hours in nulliparous women and more than 2 hours in multiparous women
(ACOG,1997)

d. Side effect; hyphotension. Usually safe for the fetus if maternal hypotension does not develop (BP is the single
Most important vital sign to be monitored with the use of regional anesthesia.)
 e. Types of regional anesthesia
. Paracervical block:
. Given in active phase of labor
.Produces rapid relief from uterine pain and contraction pain; no effect on perineal area
. Does not affect bearing-down reflex
Peridural block

 Given in active phase or second stage of labor

 Produces rapid relief of uterine and perineal pain given in single or continuous dose
 Examples:
o Epidural: commonly used; may cause maternal hypotension fetal bradycardia
o Caudal: may cause maternal h y p o t e n s i o n  f e t a l bradycardia
o Combination: spinal epidural
 Intradural:

 Given in the second stage of labor

 Flat position for 8 to 12 hours after
 Examples:
o Spinal block: relieves uterine and perineal pain; may cause maternal hypotension; rapid inset; commonly used
o Sadle block: (low spinal) for rapid relief of pain as in forceps delivery
 Pudendal block:
 Given in the second stage (episiotomy) and the third stage (repair)
 A local anesthetic agent is placed in the area of the pudendal nerve through the vigina and near the right and left
ischial spines (Cunningham, 2001; Hughes et a., 1196; Hawkins et al., 1996 :); used for spontaneous vaginal
delivery, outlet, and low forceps extraction.
 Affects perineum for 30 minutes
 Reasonably effective and very safe as it has no effect on fetus ( Hawkins et al., 1996)

4. Local Anesthesia: local anesthetic infiltration

a. involves infiltration of tissue with 10 to 20 mL local anesthic, usually lidocaine (xylocaine)

b. Given in the second stage during vaginal delivery to facilitate cutting (episitomy) or repair (episiorrhaphy) of the
perineum and vagina
c. Usually performed by the physician just before delivery of the fetal head (Hughes, levinsion, & Rosen, 2002); NOT
performed by a nurse or midwife!
d. Has the least likelihood of complications (Hawkins et al., 1996)
e. Needs sensitivity testing to xylocaine before use because of common side effects: rash, irritation, and sensitization