Complications of labor and birth

Premature Rupture of Membranes (PROM)

Is the spontaneous rupture of fetal membranes one hour or more before the onset of labor.

Incidence: 10% of all pregnancies.Causes: remains unknown in most cases.

Risk factors:

PolyhydaminosCerculageAmniocentesisPlacental abruption.InfectionMore common in twins gestation.Seldom associated with trauma.

Complications

1. Preterm delivery.2. Maternal or fetal infections:

a) Chorioamniositisb) Endometrits clinically persisting

after delivery.

3. Fetal distress a) Umbilical prolapsed more common in

cases of PROM.b) Increase rate of stillbirths in

unmonitored patients.

Evaluating the patient with PROM

Correct diagnosis is essential for future management.

Sterile speculum examination: Visualize pool of fluid in vaginal fornix Leakage of fluid through cervix.

pH of amniotic fluid is 7.1 to 7.3 Normal vaginal pH is 4.5 to 6

Nitrazine paper turns blue at pH > 6.5 Note: false positive rates (1% to 17%) by blood,

semen, vaginal infection, alkaline antiseptics or alkaline urine.

Evaluating the patient with PROM

Cervical dilation is assessed.Observe for prolapsed fetal part or umbilical cord.Collection of samples for culture.Collection of fluid for lung maturity studies.Note: don't perform digital intracervical

examination in nonlaboring patient.Ultrasound is a final confirmatory step in some

cases.Establish gestational age and fetal maturity

(history, u/s, and other dating criteria).Rule out infection: clinical manifestation e.g. fever

and cultures.Rule out fetal distress: continuous fetal heart tone

monitoring.

Management and interventions

Term patients:Immediate induction is suggested.Preterm patients: Survival rate after 26 weeks is close to 50%. If gestation is < 34 weeks, efforts are directed toward

maintaining pregnancy. Tocolytic to delay labor long enough for fetal lungs to mature with administration of corticosteroids.

Antibiotics therapyNurse monitors vital sings and describe the

characters of the amniotic fluid, uterine activity, fetal response to labor and hydration.

Uterine rupture

Uterine rupture is a spontaneous or traumatic rupture of the uterus.

Causes:

Rupture of the scar from a previous cesarean delivery or hystrotomy.

Uterine traumaCongenital uterine anomaly.Prolonged or obstructed labor.Forced delivery of fetus with abnormalities e.g.

hydrocephalus.Internal or external version.Application of forceps and extraction before cervical

os has completely dilated.Injurious use of oxytocin.Excessive manual pressure applied to the fundus

during delivery.

Clinical manifestation

1. Complete rupture:Sudden sharp abdominal pain during

contractions.Abdominal tenderness. Cessation of contractions.Bleeding into abdominal cavity and

sometimes into vagina.Fetal easily palpated, fetal heart tones cease.Signs of shock.

Clinical manifestation

2. Incomplete rupture:Develops over a period of few hours.Abdominal pain during contractions.Contractions continue, but cervix fails to

dilate.Vaginal bleeding may be present.Tachycardia, pale skin. Loss of heart tones.

Management and nursing intervention

Emergency laparotomy is performed with complete rupture, usually the uterus is removed and attempts are made to save the baby.

Administer IV fluids and blood as directed.Administer oxygen to the woman.Prepare the woman for emergency surgery.Monitor maternal and fetal vital signs until

surgery begins.Uterus may be repaired if rupture is not

extensive, if extensive hysterectomy is necessary.

Management and nursing intervention

Reduce fear and anxiety:Keep the woman informed about procedures being

done.Answer her questions as positively and as

realistically as possible.Fetal prognosis is very poor, unless delivery can be

accomplished immediately.Maternal prognosis is guarded, especially in uterine

rupture of traumatic origin (5-10 % mortality). If fetus doesn't survive, offer grief counseling. If the uterus is spared, woman is advised to have

cesarean birth with future pregnancy.

Amniotic fluid embolism.

Is the accidental infusion of amniotic fluid in to the mother's blood stream under pressure from the contracting uterus.

Amniotic fluid containing fetal vernix, lanugo, meconium, and mucus enters maternal blood sinuses through defect's in to the placental attachment.

These particles become emboli in the mother’s general circulation causing acute respiratory, circulatory collapse, hemorrhage and cor pulmonale as they block the vessels of her lungs.

These particles stimulate abnormal coagulating, initiating DIC.

Amniotic fluid embolism is rare and usually fatal (mortality rate is as high as 80% for mothers & approximately 50% of neonates)

Clinical manifestations:

Sudden dyspnea and chest pain. Cyanosis. Tachycardia.Pulmonary edema. Prolonged shock due to:

1. Anaphylaxis, which cause vascular collapse.2. Uterine bleeding with development of

hypofibrinogenemia.

Management and nursing intervention

Emergency measures: cardiopulmonary resuscitation (CPR).1. Improving tissue perfusion and cardiopulmonary function. 2. Administer O2 as soon as possible.

3. Provide assisted ventilation.4. Maintaining fluid volume and correction of DIC.5. Administer fresh whole blood and fibrinogen.6. Administer IV fluids and plasma.7. Provide continuous monitoring of maternal and fetal status.8. Delivery of fetus.9. Since fetus is in great danger, cesarean approach is used.10. Care for the neonate and provide family members with

comfort and information about the status of mother and infant.

Prolapsed Umbilical Cord

Occurs when a loop of the umbilical cord slips down below the presenting part of the fetus.

Types

Occult prolapse (hidden; not visible), occurs at any time during labor whether or not the membranes have ruptured—the cord lies beside the presenting part in the pelvic inlet.

Complete prolapse, the cord descends into the vagina, where it is felt as a pulsating mass on vaginal examination. It may or may not be seen.

Frank (visible) prolapse, most commonly occurs immediately after rupture of membranes as gravity washes the cord in front of the presenting part.

Causes

Rupture of membranes, when the presenting part is not engaged in the pelvis.

More common in shoulder & foot presentation. Prematurely: small fetus allows more space

around presenting part. Hydramnios: causes greater amount of fluid to

be related with greater force when membranes rupture.

Contracted pelvis. Placenta previa.

Clinical Manifestation

Cord may be seen protruding from vagina, or can be palpated in the vaginal canal cervix.

Signs of fetal distress: the cord is compressed between the presenting part and bony pelvis.

If cord is exposed to cold room air, there may be reflex constriction of umbilical vessels, restricting oxygen flow to fetus.

Fetal heart rate pattern may be irregular with periodic fetal bradycardia.

Management & Nursing Interventions

Maintaining oxygen supply to fetus:Until the presenting part has engaged, all women whose

membranes have ruptured should remain on bed rest.At the time of spontaneous rupture or amniotomy, FHR is

assessed continuously, if bradycardia is noticed, assess for cord prolapse.

Place the women in recovery or knee-chest position.Administer oxygen to the women.Place sterile gloved hand in vagina and push the fetal head

up ward to relief compression of the cord.Prepare of immediate vaginal delivery if cervix is dilated.Prepare of immediate cesarean delivery if cervix is not

deleted.In home situation, cover-protruding cord with clean wet

dressing. Elevate the woman's hips and transports to hospital immediately.

Management

Management

Reducing Anxiety:Have the woman/couple hear fetal heart

tones for reassurance.Keep the woman informed of procedure being

performed.When infant is born and stabilized, have the

woman/couple hold him as soon as possible for reassurance.

Uterine Inversion

Uterine inversion (uterus is turned inside out) is a rare but potentially life-threatening complication.

Possible causes:Most common cause is excessive pulling on

the umbilical cord in an attempt to hasten the third stage of delivery.

Other contributing factors include vigorous fundal pressure, uterine atony, and abnormally adherent placental tissue.

Clinical Manifestations

When complete inversion occurs, a large, red, globular mass (that may contain the still-attached placenta) protrudes 20 to 30 cm outside the vaginal introitus.

A partial or incomplete inversion is not visible; instead, a smooth mass is palpated through the dilated cervix.

Maternal symptoms include pain, hemorrhage, and shock.

Management

Involves manual replacement of the fundus (under general anesthesia) by the physician, followed by oxytocin to facilitate uterine contractions and antibiotic therapy to prevent infection.

Prevention (by not pulling strongly on the cord until the placenta has fully separated) is the safest and most effective therapy.

Labor ComplicafionsDystocia

Defined as a long, difficult or abnormal labor, is a term used to identify poor labor progression.Predisposing factors “Etiology"Any problem with powers (uterine contractions), the passenger (fetus), or the passageway (maternal pelvis).

DystociaPredisposing factors “Etiology"Any problem with powers (uterine contractions), the

passenger (fetus), or the passageway (maternal pelvis). Hypertonic or hypotonic uterine contractions. Multiple gestations. Abnormal implantation site of the placenta. Contracted pelvic. Fetopelvic disproportion. Large baby. Malposition and malpresentation. Previous experience. Poor support system.

Types of Dystocia

1. Mechanical dystocia:Maternal causes: contracted pelvis, obstructive tumor…Fetal causes: malformation of the fetus as hydrocephalus

or large size baby, malpresentation as shoulder, face or breech.

2. Functional dystocia: (uterine dysfunction or inertia).Condition in which uterine contractions deviate from the

normal contractions may be extremely forceful with a rapid and traumatic labor, more commonly, the contractions are ineffectual.

Hypotonic uterine contraction (inertia)

Defined as less than 3 contractions of mild to moderate intensity occurring in a 10 minutes period during the active phase of labor.

The intrauterine pressure (IUP) is insufficient for the progression of cervical effacement and dilation.

Cervical dilation and descent of fetus slow greatly or stop.

Hypotonic uterine contraction (inertia)

Etiology:Occurs when uterine fibers are overstretched from large

baby, twins, hydramnios, or multiparity.May also be caused by administration of sedations or

narcotics.Bowel or bladder distention.

Contractions

Complications of inertia

Potential maternal effects: Exhaustion. Postpartum hemorrhage. Stress and psychological trauma. Infection.

Potential fetal effects: Fetal sepsis (Infection). Fetal and neonatal death.

Medical management

Walking and position changes in labor assist in fetal descent through the maternal pelvis and therefore need to be encouraged.

The use of relaxation techniques & massage can decrease the need for pharmacological agents for pain.

Oxytocic stimulation of labor or prostaglandin stimulation.

Nursing interventionPelvis is reevaluated for size.IV fluids are provided to maintain hydration and

electrolyte balance.Oxytocin administration is started if pelvic size is

adequate, fetal position and presentation is normal. Monitor FHR and contractions, if contractions last more than 60-70

seconds, decrease or stop infusion to prevent rupture of uterus and premature separation of the placenta and fetal hypoxia.

Observe IV drip, be certain that infusion is running at the prescribed rate.

Report any maternal or fetal distress immediately.

Amniotomy may be performed to augment labor.Use anxiety-reducing measures to promote

psychological and emotional status.

Hypertonic uterine contractionUsually occurs in the latent phase of labor, with an

increase in frequency of contractions and a decrease in their intensity.

Contractions are strong and often painful but are ineffective in producing cervical effacement and dilation.

Hypertonic uterine contraction

An increase in maternal catecholamine release (i.e., epinephrine, norepinephrine) can result in poor uterine contractility. Uterine pacemakers (the energy source of contractions located in the uterine wall) do not initiate a good myometrial response needed for progressive cervical change. Instead, irregular spasmodic episodes occur that do not result in effective contractions or assist in bringing the fetus into a more favorable downward position

Contraction may be uncoordinated and involve only portions of the uterus.

Usually occurs before 4 cm dilation. The cause is not yet known, may be related to fear or tension.

Possible causes

Potential maternal causes: Maternal anxiety (Primiparous labor, Loss of control, Sexual

abuse, Lack of support, Cultural differences, Fear of pain)

Potential fetal causes: occiput–posterior malposition

Medical management Analgesic (morphine, meperdine) if membranes

are not ruptured and fetalopelvic disproportion isn't present.

Natural labor with effective contractions often resumes after this simple intervention.

Nonpharmacological techniques to reduce anxietyfacilitate rotation of the fetal head into a more

favorable position (walk and change positions frequently).

Nursing interventionBed rest & sedatives to promote relaxation and reduce

pain.Provide fluids to maintain hydration and electrolyte

balance.Observe for normal contractions when woman awakens.Oxytocin is not administered; it will increase the

abnormal labor pattern.Check intake and output every 2 hr.Monitor vital signs and FHR.If the condition is prolonged, check for CPD and

malpresentation, if excluded, amniotomy and oxytocin infusion may be instituted.

Reduce anxiety; give psychological and emotional support measures.

Contracted pelvisThe bony funnel of the woman’s pelvis is too

narrow at some point for the fetus to pass through

Pelvic diameter is1 cm or more less than normal (except transverse, diameter 2 cm)

Causes: Growth retardation. Growth disease e.g. T.B. Bone disease e.g. rickets.

Determine condition of pelvis by X- ray or ultrasound

Cephalopelvic disproportionIs fetal head to maternal pelvis discrepancy.The term is also used with other positions. CPD is suspected when labor is prolonged, cervical dilatation

and effacement are slow and engagement of the presenting part is delayed.

Trial labor is allowed to continue only as long as dilation and descent progress.

Cephalopelvic disproportion

If there is no progress, cesarean birth is performed.

Nursing care as contracted pelvis and other complicated labors.

Maternal complications of such labor include PROM, uterine rupture and necrosis of maternal soft tissue from pressure of the fetal head.

Fetal complications include cord prolapse, extreme molding of the skull with possible fractures and intracranial hemorrhage.

Multiple pregnancies

Introduction of ovulation inducing agents in late 1960s and assisted reproductive technologies (ART) in the 1970 caused increased number of multiple births.

Much of perinatal mortality and morbidity attributable to multiple births is due to preterm delivery.

Twin gestation:1% all births.Represent a high-risk pregnancy.

Types of twining:

Monozygotic (identical): are identical because they develop from fertilization from one fertilized oocyte (zygote) that divides into equal halves during an early cleavage phase (series of mitotic cell divisions) of development. If division occurs early (first 1-8 days), they will have two placentas. If it occurs later, they will share the same placenta.

Monozygotic

Dizygotic (fratermal):

Occurs more frequently in some families "heredity is important on mother’s side".

Occurs in response to greater levels of FSH.Increased in women greater than 35 years of age

and in obese women.More common among Africans (10 to 40/1000).May be different sexes.Always have 2 chorions, 2 amnions.Result from fertilization of 2 separate ova.Fertility drug use associated with dizygotic

twinning such as clomide and pergonal.

Complications

Maternal complications: Greater increase in blood volume, pulse, cardiac

output and weight gain. Increased rate of preterm labor, hypertension,

abruption, anemia, hydramnios, UTI, cesarean section and postpartum hemorrhage.

Infant complications: Prematurity –average age of delivery is 37 weeks. Difference in placental surface area. Donor twin→ small, pale, anemia. Recipient twin→ large, plethoric, polycythemia,

hyperbilirubinemia. Fetal anomalies occur more often in multiple pregnancies.

Triplets

Increasing frequency because of ART.Average weight gains 45 to 50 pounds.Usual spontaneous time for delivery is 32-34

weeks.Average weight of newborns is1800-1900

grams.Most delivered by cesarean section.

Quadruplets or more:

Most are a result of ART.Average gestational age 30 to 31 weeks.Average weight newborns weight is1200-

1500 grams.Multifetal reduction, has been shown to

improve perinatal survival rate.

Assessment:

Initial maternal assessment includes a family history of twinning or use of fertility drugs.

At each prenatal visit, assess fundal height, FHR, fetal development.

U/S to confirm the diagnosis.Assessment of physical discomforts such as

backache and dyspnea.Multiple pregnancies increase the incidence of

PIH, prematurity, hydramnios, abnormal fetal positions and presentations, uterine dysfunction, and postpartum hemorrhage.

Nursing intervention:To prevent premature delivery:Encourage the woman to keep appointments for more frequent

checkups.Counsel the woman to rest frequently during the day especially in

the third trimester; assist the family to mobilize support system for this purpose.

Teach the woman reportable signs and symptoms of premature labor.

Diet high in protein, iron, calcium, 300 calories added to normal pregnancy.

Monitor for hypertensive disorders.During labor, mother and fetuses are monitored closely. Ideally, the largest fetus is delivered through vertex presentation

and is the first to be born. If the first is a breech presentation or the smaller one, delivery is complicated.

Cesarean birth is recommended if fetal distress, CPD, placenta previa, or sever PIH is present or if prior cesarean birth have occurred.

Following delivery, monitor the woman for postpartum hemorrhage due to over distended uterus.

Health education:

Rest frequently on her side.Sitting with leg elevated to help relief

backache.Small frequent meals will aid digestion.