COLLEGE OF NURSING
COLLEGE OF NURSING
Silliman University
Dumaguete City
COMPLICATIONS OF LABOR & DELIVERY
Main Topic: Complications of Labor & Delivery
Placement: Second Semester, Level III
Topic Description: This topic deals with common complications of
labor and delivery; definition of terms and contributing
factors.
Central Objectives: At the end of the 2 hours lecture &
discussion, the learners will gain sufficient knowledge, develop
beginning skills, and manifest positive attitude towards
determining the different complications of labor and delivery.
SPECIFIC OBJECTIVESCONTENTTAT-L
ACTIVITIESREFERENCESEVALUATION
At the end of 1 hour lecture and discussion, the learners
shall:
a. Define correctly the terms related to Labor and Delivery at
75% level of competency.
b. Determine accurately the different complications of Labor and
Delivery at 75% level of competency.
b.1. Identify precisely the complications or problems that are
related to power/uterine contraction at 75% level of
competency.
b.2. Discuss correctly the common fetal causes of the LRDR
complications at 75% level of competency.
b.3. Efficiently identify most of the passage/pelvic
complications at 75% level of competency.
b.4. Proficiently determine the different placental anomalies at
75% level of competency.
b.5. accurately explain the two cord anomalies at 75% level of
competency.
I. Prayer
Almighty father, creator of all, you are the king of kings; we
believe and trust in you throughout eternity. Father god, we thank
you for all experiences, lessons we learned and the blessings you
have given to us. We give thanks to the gifts of life. We ask for
forgiveness of our sins weve done against you, to my brothers and
sisters and to all. We dont desire to have a lighter burden but to
strengthen our body to carry the heave loads of life. All these we
pray and ask to you father God. Amen.
II. Introduction
Labor may start too early (before the 37th week of pregnancy) or
may start late (after the 41st to 42nd week of pregnancy). As a
result, the health or life of the fetus may be endangered. Labor
may start too early or late when the woman or fetus has a medical
problem or the fetus is in an abnormal position.
No more than 10% of women deliver on their specified due date
(usually estimated to be about 40 weeks of pregnancy). About 50% of
women deliver within 1 week (before or after), and almost 90%
deliver within 2 weeks of the due date.
III. Nursing Process Overview
i. Assessment
You need do fetal and uterine monitoring in order to detect
deviations from normal in labor. Working with such apparatus
involves explaining its importance to parents, winning their
cooperation, and using judgment in reading the various
patterns.
ii. Nursing diagnosis
Common nursing diagnosis specific to a woman experiencing a
complication during labor or birth refer to specific problems. Some
examples include:
fear related to uncertainty of pregnancy outcome
anxiety related to medical procedures and apparatus necessary to
ensure health of mother and fetus
fatigue related to loss of glucose stores through work and
duration of labor
risk for ineffective tissue perfusion related to excessive loss
of blood with complication of labor
risk for injury (maternal or fetal) related to effect on mother
and fetus of a labor complication and treatment acquired
risk for injury (maternal or fetal) related to labor involving a
multiple-gestation pregnancy
anticipatory grieving related to nonviable monitoring pattern of
fetus
iii. Outcome identification and Planning
If a complication of labor occurs, identification of expected
outcomes can be difficult because the outcome that may occur is not
what the woman desires. Encouraging the couple to clarify their
priorities is helpful. Reminding the woman that her primary goal is
really to have a healthy baby may help her accept the change,
including whatever interventions are necessary to achieve her
ultimate objectives.
iv. Implementation
Interventions must be planned and performed efficiently and
effectively, based on the individual circumstances. Be certain to
provide psychological reassurance to accompany actions to fully
safeguard both the woman and her fetus.
v. Outcome Evaluation
Evaluation of client might reveal unhappiness, because not every
woman who experiences a deviation from the normal labor and birth
will be able to give birth to a healthy child. Some deviations will
be too great. Some interventions will not be maximally effective
because of individual circumstances. Some infants will die; a few
women may be left unable to bear future children. Evaluation may
lead to a new analysis that the couples chief need at that point is
to grieve for the child or for a lifestyle that can no longer be
theirs. If the outcome is positive, evaluate the couple for signs
that they are able to begin interaction with the child after their
harrowing experience. Example of outcome achievement: Client voices
confidence that she can cope with the fear she feels about her
fetus welfare.
IV. Common complications of Labor and Delivery
3.1. Power
3.1.1 Ineffective Uterine Contraction
Uterine contractions are the basic force moving the fetus
through the birth canal. It happens because of the interplay of
contractile hormones (adenosine triphosphate, estrogen, and
progesterone) and the influence of major electrolytes such as
calcium, sodium, and potassium, specific contractile protein (actin
and myosin), epinephrine and norepinephrine, oxytocin, and
prostaglandins.
Abnormal contractions may occur which includes hypotonic
contractions, hypertonic contractions and uncoordinated
contractions. These are ineffective contraction which also results
to ineffective labor.
There are methods in evaluating the uterine activity such as
Electronic Uterine Monitoring and Montevideo units. These will
monitor the duration, strength, and interval between
contractions.
3.1.1.1 Hypotonic Contractions
With hypotonic uterine contraction, the number of contraction is
usually low or infrequent (not increasing beyond two or three in a
10-minute period). The resting tone of the uterus remains below
10mmHg, and the strength of contractions does not rise above
25mmHg. Hypotonic contractions are most apt to occur during the
active phase of labor. They may occur when analgesia has been
administered too early (before cervical dilatation of 3 to 4 cm) or
when bowel or bladder distention prevents descent or firm
engagement. They may occur in a uterus overstretched by a multiple
gestation, a larger-than-usual single fetus, or hydramnios, or in a
uterus lax from grand multiparity. Such contractions are not
exceedingly painful, because of the lack of intensity.
Hypotonic contractions increase the length of labor, because
more of them are necessary to achieve cervical dilatation. During
the postpartal period, the uterus can be exhausted from a long
labor and may not continue to contract as effectively, thus
increasing the womans chance for postpartal hemorrhage. With the
cervix dilated for a long period, both the uterus and the fetus are
at greater risk for infection.
For these reason, after ultrasonic confirmation rules out
cephalopelvic disproportion, an oxytocin infusion to augment labor
usually is started to strengthen contractions and increase their
effectiveness. Membranes may be artificially ruptured (amniotomy)
to further speed labor.
3.1.1.2 Hypertonic Contractions
Hypertonic uterine contractions are marked by an increase in
resting one to more than 15mmHg. However, the intensity of the
contraction may be no stronger than that associated with hypotonic
contractions. Hypertonic contractions tend to occur frequently;
they are most commonly seen in the latent phase of labor.
Hypertonic contractions occur because the muscle fibers of the
myometrium do not repolarize after a contractions, thereby wiping
it clean to accept a new pacemaker stimulus. They are believed to
occur because more than one pacemaker is stimulating the
contractions. Hypertonic contractions tend to be painful, because
the myometrium becomes tender from constant lack of relaxation and
resultant anoxia to uterine cells. The woman may become frustrated
or disappointed with the breathing exercises for childbirth,
because they are ineffective in achieving pain relief.
The lack of relaxation between contractions does not allow
optimal uterine artery filling, which may lead to fetal anoxia
early in the latent phase of labor. Any woman whose pain seems out
of proportion to the quality of her contractions should have both a
uterine and fetal external monitor applied for at least 15-minute
interval to ensure the resting phase of the contractions is
adequate and the fetal pattern is not showing late deceleration.
Both the woman and her support person need to understand that,
although the contractions are strong, they are, in reality,
ineffective and are not achieving cervical dilatation.
3.1.1.3 Uncoordinated Contractions
Normally, all contractions are initiated at one pacemaker point
in the uterus. A contraction sweeps down over the uterus,
encircling it; repolarization occurs, a low resting tone is
achieved, and another pacemaker-activated contraction begins. With
uncoordinated contractions, more than one pacemaker may be
initiating contractions, or receptor points in the myometrium are
acting independently of the pacemaker. Uncoordinated contractions
may occur so closely together that they do not allow good cotyledon
filling. Because they occur so erratically (one on top of another
and then a long period without any), it may be difficult for the
woman to rest or use breathing exercises between contractions.
Applying a fetal and uterine external monitor and assessing the
rate, pattern, resting tone, and fetal response to contractions for
at least a 15-minute interval (a longer time may be necessary to
show the disorganized pattern in early labor) reveals the abnormal
pattern. Oxytocin administration maybe helpful in uncoordinated
labor to stimulate a more effective and consistent patter of
contractions with a better, lower resting tone.
3.1.2 Dysfunctional Labor
As stated previously, dysfunctional or ineffective labor can
occur at any point in labor. Regardless of when dysfunctional labor
occurs, the effect on the woman and her support person will be the
same: anxiety, fear, or discouragement.
3.1.2.1. Dysfunction at the First Stage of Labor.
The major dysfunction that can occur in the first stage of labor
is a prolonged latent phase. A prolonged latent phase, as defined
by Friedman, is a latent phase that is longer than 20 hours in a
nullipara and 14 hours in a multipara. This may occur if the cervix
is not ripe at the beginning of labor and time has to be spent
getting truly ready for labor. It may occur if there is excessive
use of an analgesic early in labor. With a prolonged latent phase,
the uterus tends to be in a hypertonic state. Relaxation between
contractions is inadequate, and the contractions are only mild
(less than 15mmHg on a monitor printout) and therefore ineffective.
One segment of the uterus may contract with more fore than another
segment.
A protracted active phase is usually associated with
cephalopelvic disproportion (CPD) or fetal malposition, although it
may reflect ineffective myometrial activity. This phase is
prolonged if cervical dilatation does not occur at a rate of
1.2cm/h or more in a nullipara or 1.5cm/h or more in a multipara or
if the active phase lasts over 12 hours in a primigravida, 6 hours
in multigravida. If the cause of the delay in dilatation is fetal
malposition or CPD, cesarean birth may be necessary.
A deceleration phase has become prolonged when it extends beyond
3 hours in a nullipara and 1 hour in a multipara. Prolonged
deceleration phase most often results from abnormal fetal head
position. A cesarean birth is frequently required.
A secondary arrest of dilatation has occurred when there is no
progress in cervical dilatation for more than 2 hours.
3.1.2.2 Dysfuncional at the Second Stage of Labor.
Prolonged Descent. Prolonged descent of the fetus occurs if the
rate of descent is less than 1.0cm/h in a nullipara or less than
2.0cm/h in a multipara.
With both a prolonged active phase of dilatation and prolonged
descent, contractions have been of good quality and proper
duration, and effacement and beginning dilatation have occurred.
But then, the contractions become infrequent and of poor quality,
and dilatation stops. If everything except the suddenly faulty
contractions is normal (CPD or poor fetal presentation has been
ruled out by sonogram), then rest and fluid intake, as advocated
for hypertonic contractions, also apply. If membranes have not
ruptured, rupturing them at this point may be helpful. Intravenous
oxytocin may be used to induce the uterus to contract effectively.
A semi-Fowlers position, squatting, kneeling, or more effective
pushing may speed descent.
Arrest of descent results when no descent has occurred for 1
hour in a multipara, or 2 hours in a nullipara. Failure of descent
has occurred when expected descent of the fetus does not begin
(engagement or movement beyond 0 station has not occurred).
3.1.3 Contraction Rings
Two types of contraction rings can occur in a dysfunctional
labor. A simple type is a constriction ring, which can occur at any
point in the myometrium and at any time during labor. The most
common is a pathologic retraction ring (Bandls ring) that occurs at
the juncture of the upper and lower uterine segments. This is a
warning sign that severe dysfunctional labor is occurring. The ring
usually appears during the second stage of labor as a horizontal
indentation across the abdomen. It is formed by excessive
retraction of the upper uterine segment; the uterine myometrium is
much thicker above than below the ring.
When a pathologic retraction ring occurs in early labor, it is
usually from uncoordinated contractions. In the pelvic division of
labor, it is usually caused by obstetric manipulation or the result
of the administration of oxytocin. The fetus is gripped by the
retraction ring and cannot advance beyond point. The undelivered
placenta will also be held at that point.
Most likely, a cesarean birth will be necessary to ensure safe
birth of the fetus. Manual removal of the placenta under general
anesthesia may be required if the retraction ring does not allow
the placenta to be delivered.
3.1.4 Precipitate Labor
Precipitate and birth occur when uterine contractions are so
strong that the woman gives birth with only few rapidly occurring
contractions. It is often defined as a labor that is completed in
fewer than 3 hours. Such rapid labor is likely to occur with
multiparity or may follow induction of labor by oxytocin or
amniotomy. Contractions may be so forceful they lead to premature
separation of the placenta, placing the mother and fetus at risk
for hemorrhage. Rapid labor also poses a risk to the fetus because
subdural hemorrhage may result from the sudden release of pressure
on the head. The woman may sustain lacerations of the birth canal
from the forceful birth. She also can feel overwhelmed by the speed
of labor.
A precipitate labor can be predicted from a labor graph if,
during the active phase of dilatation, the rate is greater than
5cm/h (1cm every12 minutes) in a nullipara and more than 10cm/h (1
cm every 6 minutes) in a multipara. If this is occurring, a
tocolytic may be administered to reduce the force and frequency of
contractions.
3.1.5 Uterine Rupture
Rupture of the uterus during labor, although rare (occurring
only in about1 in 1500 births), is always a possibility. A uterus
ruptures when it undergoes more strain than it is capable of
sustaining. Rupture occurs most commonly when a vertical scar from
a previous cesarean birth or hysterectomy repair tears.
Contributing factors may include prolonged labor, faulty
presentation, multiple gestation, unwise use of oxytocin,
obstructed labor, and traumatic maneuvers using forceps or
traction. Uterine rupture accounts for as many as 5% of all
maternal deaths. When it occurs, fetal death will occur unless
immediate cesarean birth can be accomplished. In these instances,
fetal outcome can be optimal.
Impending rupture is preceded by a pathologic retraction ring
(an indention is apparent across the abdomen over the uterus) and
strong uterine contractions without any cervical dilatation. To
prevent rupture when these symptoms are present, anticipate the
need for an immediate cesarean birth. If a uterus should rupture,
the woman experiences a sudden, severe pain during a strong labor
contraction. She may report a tearing sensation. Rupture can be
complete, going through endometrium, myometrium, and peritoneum, or
incomplete, leaving the peritoneum intact. With a complete rupture,
uterine contractions will stop. There is hemorrhage from the torn
uterus into the abdominal cavity and possibly into the vagina.
Signs of shock begin, including rapid, weak pulse, falling blood
pressure, cold and clammy skin, and dilatation of the nostrils from
air hunger. The womans abdomen will change in contour. Two distinct
swellings will be visible: the retracted uterus and the
extrauterine fetus. Fetal heart sounds become absent. If the
rupture is incomplete, the signs are less evident than in complete
rupture. With an incomplete rupture, the woman may experience only
a localized tenderness and a persistent aching pain over the area
of the lower segment. Fetal heart sounds, a lack of contractions.
And the womans vital signs will gradually reveal fetal and maternal
distress.
It is inadvisable for a woman to conceive again after a rupture
of the uterus unless it occurred in the inactive lower segment.
Therefore, the physician, with consent, may perform a hysterectomy
(removal of the damaged uterus) or tubal ligation at the time of
the laparostomy. Both procedures result in loss of childbearing
ability.
3.1.6 Uterine Inversion
Uterine inversion is a rare phenomenon, occurring in about 1 in
15,000 births, in which the uterus turns inside out. It may occur
after the birth of the infant if traction is applied to the
umbilical cord to remove the placenta or if pressure is applied to
the uterine fundus when the uterus is not contracted. It may also
occur when the placenta attaches at the fundus, so that during
birth, the passage of the fetus pulls the fundus down.
Inversion occurs in various degrees. The inverted fundus may lie
within the uterine cavity or the vagina or, as in total inversion,
protrude from the vagina. When an inversion occurs, a large amount
of blood suddenly gushes from the vagina. The fundus is not
palpable in the abdomen. If the loss of blood continues unchecked
for more than a few minutes, the woman will immediately show signs
of blood loss: hypotension, dizziness, paleness, or diaphoresis.
Since the uterus is not contracted in this position, bleeding
continues. A woman could exsanguinate within a period as short as
10 minutes.
Never attempt to replace the inversion because handling may
increase the bleeding. Never attempt to remove the placenta if it
is still attached, because this will only create a larger surface
area for bleeding. In addition, administering an oxytocic drug only
compounds the inversion. An intravenous fluid line needs to be
started, if one is not already present (if doing this, use a
large-gauge needle because blood will need to be replaced).
3.1.7 Amniotic Fluid Embolism
Amniotic fluid embolism occurs when amniotic fluid is forced
into an open maternal uterine blood sinus through some defect in
the membranes or after membrane rupture or partial premature
separation of the placenta. Previously, it was thought that
particles such as meconium or shed fetal skin cells in the amniotic
fluid entered the maternal circulation and reached the lungs as
small emboli. Now, it is recognized that a humoral or anaphylactoid
response is the more likely cause. This condition may occur during
labor or in the postpartal period. The incidence is no more than 1
in 8000 births; it is not preventable because it cannot be
predicted. Possible risk factors include oxytocin administration,
abruption placentae, and hydramnios.
The clinical picture is dramatic. The woman, in strong labor,
sits up suddenly and grasps her chest because of sharp pain and
inability to breathe (secondary to pulmonary artery constriction).
She become pale and then turns the typical bluish gray associated
with pulmonary embolism and lack of blood flow to the lungs. The
immediate management is oxygen administration by facemask or
cannula. Within minutes, the woman will need CPR. CPR may be
ineffective, because these procedures (inflating the lungs
massaging the heart) do not relieve the pulmonary constriction.
Therefore, blood still cannot circulate to the lungs. Death may
occur in minutes.
The womans prognosis depends on the size of the embolism and the
skill and speed of emergency interventions. Even if she survives
the initial insult, the risk for disseminated intravascular
coagulation (DIC) developing is high, further compounding her
condition. In this event, she will need continued management that
includes endotracheal intubation to maintain pulmonary function and
therapy with fibrinogen to counteract DIC. The woman most likely
will be transferred to an ICU. The prognosis for the fetus is
guarded, because reduced placental perfusion results from the
severe drop in maternal blood pressure. Labor often begins or the
fetus is delivered immediately by cesarean birth.
3.2 Passenger
3.2.1 Umbilical Prolapse
A complication wherein the umbilical cord of the fetus slips
down in front of the presenting part. This condition happens when
the presenting part is not well fitted into the cervix after the
bag of water ruptures. In addition, this condition often happens
when the fetus is in breech presentation wherein the cervix is not
well blocked by the presenting part.
The conditions that most often results to Umbilical Cord
Prolapse are the following:
1. PROM or Premature Rupture Of Membrane
This condition is characterized by the spontaneous rupture of
amniotic sac before the onset of labor.
2. Fetal presentation other than cephalic such as breech
presentation.
In Breech presentation (Frank and Footling), the presenting part
does not fit tightly in the cervix thus leaving a space for the
umbilical cord to slip down.
3. Placenta previa
In this condition, the placenta is abnormally implanted in the
uterus thus covering the internal os of the uterine cervix.
Complete previa this refers to a placenta that has grown and
completely covers the internal cervical os.
Low-lying placenta refers to a placenta that is just within the
lower uterine segment.
Partial or Marginal previa refers to a placenta that partially
covers the internal os.
4. Intrauterine tumors
The location of intrauterine tumors is important. If the tumor
is located in such a way that it prevents the presenting part to
fit tightly in the cervix , then cord prolapse is most likely to
happen.
5. Relatively small fetus
Even if the pregnant mother has an average birth canal, if her
baby is small, then there will be enough room for the cord to slip
down the cervix and eventually will be visible in the vaginal.
6. CPD or Cephalopelvic Disproportion
In this condition, the babys head is too large or the mothers
birth canal is too small to permit normal labor or birth.
Relative CPD the size of the babys head is within normal limits
but larger than average or the size of the mothers birth canal is
within normal limits but smaller than the average.
Absolute CPD the babys head is abnormally enlarged or the
mothers birth canal is abnormally contracted.
7. Hydramnios
This is a condition wherein the amniotic sac contains excess or
extra volume of amniotic fluid.
8. Multiple gestation
Multiple fetuses increases the risk of cord prolapse after the
rupture of membranes and abnormal fetal presentations may also
occur.
Cord prolapse in this situation usually occurs after the first
baby is delivered.
3.2.2 Multiple Gestation
The possibilities of cord entanglement, premature separation of
the placenta, abnormal fetal presentation, uterine dysfunction, and
overstretched uterus are increased during multiple gestations since
there are more than two fetuses in the womb unless they are
Dichorionic Diamniotic (separate placentae). Cesarean sectioning is
a primary option because of the risk that the second fetus will
experience anoxia.
3.2.3 Presentation, Position, or Size
1. Occipitoposterior position
A presenting head, posteriorly positioned, does not fit tightly
compared to a presenting head which is anteriorly positioned. This
position increases the risk of umbilical cord prolapse. Mothers
delivering their babies with this position experience pressure and
pain in their lower back due to sacral nerve compression.
2. Breech presentation
The fetus buttocks along with the legs take up more space
compared to the fetal head which has the widest single diameter.
Meconium staining in the amniotic fluid while the fetus is still
inside the uterus occurs due to the unavoidable contraction of the
fetal buttocks into the cervix. Compared to cephalic presentation,
breech presentation allows the following complications to
occur:
a. Anoxia a result of cord prolapse.
b. Traumatic injury to the aftercoming head such as intracranial
hemorrhage.
c. Fracture spine or arm of the fetus.
d. Dysfuctional labor or ineffective labor
e. Early rupture of membranes because the presenting part is
poorly fitted to the cervix.
3. Face presentation (chin or mentum)
In this type of presentation, the head diameter of the fetus
presenting to the pelvis is often too large for birth to proceed.
Babies born after a face presentation have a great deal of facial
edema and may be purple from ecchymotic bruising.
4. Brow presentation
The rarest of all presentations. This presentation almost always
results in obstructed labor because the head comes jammed in the
brim of the pelvis as the occipitomental diameter presents. This
type of presentation, like face presentation, also leaves the
infant with extreme ecchymotic bruising on the face.
5. Transverse Lie
In this position, the membranes rupture at the beginning of
labor. The umbilical cord and arm may prolapse and the shoulder may
obstruct the cervix since there is no firm presenting part. The
mature fetus cannot be delivered vaginally thus; mothers opt to
undergo cesarean section.
6. Oversized fetus / Macrosomia
An oversized fetus may cause uterine dysfunction during labor or
at birth because of overstretching of the myometrium, fetal pelvic
disproportion, or even uterine rupture from obstruction. Mothers
delivering oversized fetuses have increased risk of hemorrhage due
to overly distended uterus which may not contract easily and
readily.
7. Shoulder Dystocia
This condition is hazardous to both the mother and fetus because
it can possibly result to cervical or vaginal tearing and cord
compression which is fatal respectively. The force of birth or
contraction can result to fractured clavicle or brachial plexus
injury for the fetus.
8. Fetal anomalies
There are a couple of fetal anomalies which can complicate the
birthing process since the presenting part does not engage well in
the cervix. Among these fetal anomalies are the hydrocephalus and
anencephaly.
3.3 Passage
3.3.1 Inlet Contraction
Inlet contraction is the narrowing of the anteroposterior
diameter to less than 11 cm, or of the transverse diameter to 12 cm
or less. Inlet contraction is usually caused by rickets in early
life or by an inherited small pelvis. Rickets is rare in developed
countries but can occur among immigrants who were raised in an
underdeveloped country where milk supplies were not plentiful. In
primigravidas, the fetal head normally engages between weeks 36 to
38 of pregnancy. If this occurs before labor begins, it is a proof
that the pelvic inlet is adequate. Following the general rule that
what goes in, comes out, a head that engages or proves it fits into
the pelvic brim will probably also be able to pass through the
midpelvic and through the outlet.
In primigravidas, if engagement does not occur, then either a
fetal abnormality (larger-than-usual head) or a pelvic abnormality
(smaller-than-the-usual) should be suspected. On the other hand,
engagement does not occur in multigravidas until labor begins
because previous birth of a full term infant is a proof that their
birth canals are adequate. Every primigravidas should have pelvic
measurements taken and recorded before week 24 of pregnancy so that
birth decision can be made with the assumption that the fetus will
be of average size.
The treatment goal is to allow the natural forces of labor to
push the biparietal diameter of the fetal head beyond the potential
interspinous obstruction. Although forceps may be used, they cause
difficulty because pulling on the head destroys flexion, and the
space is further diminished. A bulging perineum and crowning
indicate that the obstruction has been passed.
3.3.2 Outlet Contraction
The interischial tuberous diameter of less than 8 cm constitutes
an outlet contracture. Outlet and midpelvic contractures frequently
occur simultaneously. Whether vaginal birth can occur depends on
the womans interischial tuberous diameter and the fetal
posteriosagittal diameter. This measurement is easy to make during
prenatal visit, so the narrow diameter can be anticipated before
labor begins. It is also easily reassessed during labor since you
already have the baseline data during the prenatal visits.
3.3.3 Trial Labor
If a woman has a borderline or just adequate inlet measurement
and the fetal lie and position is good, her physician may allow her
a trial labor to determine whether the labor can progress normally.
A trial labor continues as long as descent of the presenting part
and dilatation of the cervix are occurring.
Our nursing responsibilities include the monitoring of fetal
heart sounds and uterine contractions continuously, if possible,
during this time. Urge the woman to void every 2 hours so that her
urinary bladder is as empty as possible, allowing the fetal head to
use all the space available. After rupture of the membranes, assess
FHR carefully; if the fetal head is still high, there is an
increased danger of prolapsed cord and anoxia in the fetus. If
after a definite period (6 to 12 hours) adequate progress in labor
cannot be documented, or if at any time fetal distress occurs, the
woman will be scheduled for a cesarean birth.
Reassure the woman and her support person that a cesarean birth
is an alternative, not an inferior, method of birth. In this
instance, because labor is not progressing, it is the method of
choice, because it will allow them to achieve their goal of a
healthy mother and healthy child.
3.3.4 External Cephalic Version
External cephalic version is the turning of the fetus from a
breech to a cephalic position before birth. It may be done as early
as 34 to 35 weeks, although the usual time is 37 to 38 weeks of
pregnancy. For the procedure, FHR and possibly ultrasound are
recorded continuously. A tocolytic agent may be administered to
help relax the uterus. The breech and vertex of the fetus are
located and grasped transabdominally by the examiners hands on the
womans abdomen. Gentle pressure is then exerted to rotate the fetus
in a forward direction to a cephalic lie. The use of external
version can decrease the number of cesarean births necessary from
breech presentations. Contraindication to the procedure include
multiple gestation, severe oligohydramnios, contraindications to
vaginal birth, a cord that wraps around the neck, and unexplained
third-trimester bleeding, which might be placenta previa. External
version can be uncomfortable for the woman because of the feeling
of pressure. Women who are Rh negative should receive Rh
immunoglobulin after the procedure in case minimal bleeding
occurs.
3.4 Placental Anomalies
3.4.1 Placenta Succenturiata
Placenta Succenturiata has one or more accessory lobes connected
to the main placenta by blood. However, it is important that it be
recognized, because the small lobes may be retained in the uterus
after birth, leading to severe maternal hemorrhage. On inspection,
the placenta appears torn at the edge of the placenta. The
remaining lobes must be removed from the uterus manually to prevent
maternal hemorrhage from poor uterine contraction.
3.4.2 Placenta Circumvallata
Ordinarily, the chorion membrane begins at the edge of the
placenta and spreads to envelop the fetus, no chorion covers the
fetal side of the placenta. In placenta circumvallata, the fetal
side of the placenta is covered to some extent with chorion. The
umbilical cord enters the placenta at the usual midpoint, and large
vessels spread out from there. They end abruptly at the point where
the chorion folds back onto the surface, however. Although no
abnormalities are associated with this type of placenta, its
presence should be noted. There is an increased risk of repeated,
small prenatal hemorrhages resulting in preterm birth. There also
is an increased risk of retained placenta leading to postpartum
hemorrhage.
3.4.3 Battledore Placenta
Battledore placenta is when the cord inserts at the placental
margin rather than in the center of the placenta as with normal
insertion. This anomaly is rare and has no known clinical
significance.
3.4.4 Velamentous Insertion of the Cord
Velamentous insertion of the cord is a situation in which the
cord, instead of entering the placenta directly, separates into
small vessels that reach the placenta by spreading across a fold of
amnion. This form of cord insertion is most frequently found with
multiple gestation. Because it may be associated with fetal
anomalies, the newborn should be examined carefully.
3.4.5 Vasa Previa
In vasa previa, the umbilical vessels of a velamentous cord
insertion cross the cervical os and therefore deliver before the
fetus. The vessels may tear with cervical dilatation, just as a
placenta previa may tear. Before inserting any instrument such as
an internal fetal monitor, structures should be identified to
prevent accidental tearing of a vasa previa. Tearing would result
in sudden fetal blood loss. If sudden, painless bleeding occurs
with the beginning of cervical dilatation, vasa previa should be
suspected. It can be confirmed by sonography. If vasa previa is
identified, the infant needs to be born by cesarean birth.
3.4.6 Placenta Accreta
Placenta Accreta is an unusually deep attachment of the placenta
to the uterine myometrium. The placenta will not loosen and
deliver. Attempts to remove it manually may lead to extreme
hemorrhage because of the deep attachment. Hysterectomy or
treatment with methotrexate to destroy the still-attached tissue
may be necessary. Placenta accrete is the result of partial or
total absence of the deciduas basalis, which allows the placental
villi to attach to the myometrium.
3.5 Cord Anomalies
3.5.1 Two-vessel Cord
Fetuses with only two vessels, instead of having three (1 vein
and 2 arteries), needs to be carefully observed for other anomalies
during the newborn period and later in infancy. Having only 2 blood
vessels instead of 3 is associated with congenital heart and kidney
anomalies.
3.5.2 Unusual Cord Length
Unusually short umbilical cord length can result to premature
separation of the placenta and abnormal fetal lie.
III. Evaluation
2 min.
5 min.
15 min.
15 min.
10 min.
5 min.
3 min.
5 min.Socialized discussion with the use of pictures.
Socialized discussion
Lecture discussion
Socialized discussion
Socialized discussionMosbys Pocket Dictionary of Medicine,
Nursing & Allied Helath , 4th Ed. Philippines: 2002
Potter, P. & Perry Fundamentals of Nursing, 5th Ed. Mosby:
St. Louis, 2001
Cabbe, Niebyl and Simpson. Obstetrics Normal & Problem
Pregnancies, 3rd Ed. Churchill Livingstone Inc.: USA, 1996
Norak, J.C. & Broom, B.C. Maternal & Child Health, 5th
Ed. Mosby: USA, 1996
Lowdermilk, Perry, & Bobak. Maternal Nursing, 5th Ed. Mosby
Inc.: USA, 1999
Elizabeth Jean Dickason, etal. Maternal-Infant Nursing Care, 3rd
Ed. Mosby: London, 1998
Pillitteri, Adele. Maternal & Child Health Nursing, 5th Ed.
Lippincot Williams & Wilkins: London, 2007.
Pillitteri, Adele. Maternal & Child Health Nursing, 5th Ed.
Lippincot Williams & Wilkins: London, 2007.
Define or discuss terms at 75% level of competency included in a
10 item quiz.
State and briefly define or describe at least 2 labor and
delivery complications on the following, at 75% level of competency
included in a 10 item quiz:
1. Power
2. Passenger
3. Passage
4. Placental Anomalies
5. Cord Anomalies
SILLIMAN UNIVERSITY
COLLEGE OF NURSING
Dumaguete CityNURSING CARE MANAGEMENT 102
RESOURCE UNIT ON COMPLICATIONS OF LABOR AND DELIVERY
Submitted By:
Student Nurses:
Paul Jasper Sinda
Sheena Torremocha
Submitted To:
Ms. Dove Christian Sumagang R.N.
Clinical Instructor
LRDR Rotation
References:
Cabbe, Niebyl and Simpson. Obstetrics Normal & Problem
Pregnancies, 3rd Ed. Churchill Livingstone Inc.: USA, 1996
Elizabeth Jean Dickason, et al. Maternal-Infant Nursing Care,
3rd Ed. Mosby: London, 1998
Lowdermilk, Perry, & Bobak. Maternal Nursing, 5th Ed. Mosby
Inc.: USA, 1999
Mosbys Pocket Dictionary of Medicine, Nursing & Allied
Health, 4th Ed. Philippines: 2002
Norak, J.C. & Broom, B.C. Maternal & Child Health, 5th
Ed. Mosby: USA, 1996
Pillitteri, Adele. Maternal & Child Health Nursing, 5th Ed.
Lippincot Williams & Wilkins: London, 2007.
Potter, P. & Perry Fundamentals of Nursing, 5th Ed. Mosby:
St. Louis, 2001
