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Complications of Labor and Delivery
by: Ann Hearn RNC, MSNSpring 2009
Complications of Labor and Delivery
by: Ann Hearn RNC, MSNSpring 2009
Copyright © 2005 by Elsevier, Inc. All rights reserved.
The PowersThe Powers
Complications • Uterine Dystocia -defined as difficult
labor.– Hypertonic contractions – more
frequent but decreased intensity– Hypotonic contractions – decrease in
frequency (2-3 UC in 10 min period)• Also termed uterine inertia
Complications • Uterine Dystocia -defined as difficult
labor.– Hypertonic contractions – more
frequent but decreased intensity– Hypotonic contractions – decrease in
frequency (2-3 UC in 10 min period)• Also termed uterine inertia
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Interventions for Uterine DystociaInterventions for Uterine Dystocia
Hypertonic Uterus: Contractions are painful but ineffective resulting in prolonged latent phase.
• Nursing Interventions:– Bed rest– Sedation or pain relief– Support/educate– Position changes– Comfort measures: calm environment,
music, therapeutic touch, back rub, warm shower, imagery
Hypertonic Uterus: Contractions are painful but ineffective resulting in prolonged latent phase.
• Nursing Interventions:– Bed rest– Sedation or pain relief– Support/educate– Position changes– Comfort measures: calm environment,
music, therapeutic touch, back rub, warm shower, imagery
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Interventions for Uterine DystociaInterventions for Uterine Dystocia
Hypotonic Uterus: results from overstretched uterine muscle leading to a prolonged active phase.
• Nursing Interventions:– Amniotomy– Pitocin administration– Emptying bladder– Hydration– Teaching/Support
Hypotonic Uterus: results from overstretched uterine muscle leading to a prolonged active phase.
• Nursing Interventions:– Amniotomy– Pitocin administration– Emptying bladder– Hydration– Teaching/Support
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Amniotomy/Artificial Rupture of Membranes (AROM)Amniotomy/Artificial Rupture of Membranes (AROM)
• Advantages:Advantages:– Increases frequency and intensity of uterine
contractions– Release of prostaglandins– Facilitates decent of presenting part– Allows for internal monitoring– Ability to assess amniotic fluid
• Disadvantages:Disadvantages:– Increased risk for infection– Possibility of prolapsed umbilical cord
• Advantages:Advantages:– Increases frequency and intensity of uterine
contractions– Release of prostaglandins– Facilitates decent of presenting part– Allows for internal monitoring– Ability to assess amniotic fluid
• Disadvantages:Disadvantages:– Increased risk for infection– Possibility of prolapsed umbilical cord
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Artificial Rupture of MembranesArtificial Rupture of Membranes
Fig. 20-1d
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Amniotomy/Artificial Rupture of Membranes (AROM)Amniotomy/Artificial Rupture of Membranes (AROM)
• Nursing careNursing care– Place disposable pads and towel
under-buttock and change frequently– Assess FHR before and after
amniotomy
• Contraindication:Contraindication:**Procedure should not be performed
if head is not engaged**
• Nursing careNursing care– Place disposable pads and towel
under-buttock and change frequently– Assess FHR before and after
amniotomy
• Contraindication:Contraindication:**Procedure should not be performed
if head is not engaged**
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Bishop ScoreBishop Score
• Pre-labor status evaluation scoring system– A predictor for the potential success
of induction of labor– A high score indicates the cervix is
favorable and vaginal delivery will likely occur
• Pre-labor status evaluation scoring system– A predictor for the potential success
of induction of labor– A high score indicates the cervix is
favorable and vaginal delivery will likely occur
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Induction of LaborBishop ScoreInduction of LaborBishop Score
Score 0 1 2 3Dilation <1cm 1-2cm 2-4cm >4cmEffacement
0-30% 40-50% 60-70% 80%
Fetal Station
-3 -2 -1, 0 +1, +2
Cervical Consistency
Firm Intermediate
Soft
Cervical Position
Posterior Intermediate
Anterior
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Pitocin (Oxytocin) AdministrationPitocin (Oxytocin) Administration
Uses of Pitocin:Uses of Pitocin:
• Induction – initiates uterine contractions
• Augmentation – enhances ineffective contraction pattern
Goal:Goal:
A labor pattern with uterine contractions occurring every 2-3 minutes, lasting 40-60 seconds and a return to baseline between contractions
Uses of Pitocin:Uses of Pitocin:
• Induction – initiates uterine contractions
• Augmentation – enhances ineffective contraction pattern
Goal:Goal:
A labor pattern with uterine contractions occurring every 2-3 minutes, lasting 40-60 seconds and a return to baseline between contractions
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Indications for Induction (ACOG, 1999) Indications for Induction (ACOG, 1999)
– Diabetes mellitusDiabetes mellitus– Renal diseaseRenal disease– PreeclampsiaPreeclampsia– Premature Premature
rupture of rupture of membranesmembranes
– History of rapid History of rapid laborlabor
– Diabetes mellitusDiabetes mellitus– Renal diseaseRenal disease– PreeclampsiaPreeclampsia– Premature Premature
rupture of rupture of membranesmembranes
– History of rapid History of rapid laborlabor
– ChorioamnionitisChorioamnionitis– Postterm Postterm
gestationgestation– Mild abruptio Mild abruptio
placenta placenta – IUFDIUFD– IUGRIUGR
– ChorioamnionitisChorioamnionitis– Postterm Postterm
gestationgestation– Mild abruptio Mild abruptio
placenta placenta – IUFDIUFD– IUGRIUGR
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Pitocin (Oxytocin) AdministrationPitocin (Oxytocin) Administration
• Nursing interventions when titrating Pitocin:– maternal V/S– FHR pattern
• Baseline• Variability• Periodic changes
– Uterine contraction pattern• Frequency • Duration• Interval
• Nursing interventions when titrating Pitocin:– maternal V/S– FHR pattern
• Baseline• Variability• Periodic changes
– Uterine contraction pattern• Frequency • Duration• Interval
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Failure to ProgressFailure to Progress
Prolonged Labor
• Causes:– Labor dystocia– Malposition– Malpresentation– Macrosomia
• Interventions:– R/O CPD– Uterine rest– Pitocin augmentation
Prolonged Labor
• Causes:– Labor dystocia– Malposition– Malpresentation– Macrosomia
• Interventions:– R/O CPD– Uterine rest– Pitocin augmentation
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Precipitous LaborPrecipitous Labor
Labor < 3 hours
• Complications:– Woman
• loss of coping ability• Lacerations of cervix, vagina, perineum
– Fetus • Hypoxia• Cerebral trauma • Pnemothorax
Labor < 3 hours
• Complications:– Woman
• loss of coping ability• Lacerations of cervix, vagina, perineum
– Fetus • Hypoxia• Cerebral trauma • Pnemothorax
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Precipitous LaborPrecipitous LaborMonica, a G1, P0 @ 39.4wks is admitted to L&D with
occasional uterine contractions that started soon after her BOW broke an hour ago. She pauses during conversation to breath during contractions and gives a pain rating of 5. Monica states she will probably want an epidural.
While performing the admission history/assessment you notice that Monica’s contractions are occurring every 2 minutes and palpate strong. Monica is beginning to demonstrate difficulty with coping during contractions. Monica grunts during her last contraction.
What nursing interventions will you provide?
Monica, a G1, P0 @ 39.4wks is admitted to L&D with occasional uterine contractions that started soon after her BOW broke an hour ago. She pauses during conversation to breath during contractions and gives a pain rating of 5. Monica states she will probably want an epidural.
While performing the admission history/assessment you notice that Monica’s contractions are occurring every 2 minutes and palpate strong. Monica is beginning to demonstrate difficulty with coping during contractions. Monica grunts during her last contraction.
What nursing interventions will you provide?
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The PassengerThe Passenger
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Malposition of the FetusMalposition of the Fetus
• Medical Treatments:– Rotation and delivery by:
• forceps• vacuum assisted devise
• Medical Treatments:– Rotation and delivery by:
• forceps• vacuum assisted devise
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Internal & External Rotation (version)Internal & External Rotation (version)
A procedure performed to change the fetal presentation
• Internal– Podalic- changing the position of the
2nd twin after delivery of the 1st via vaginal manipulation
• External– Manual rotation of the fetus from
breech to cephalic presentation via external manipulation of the maternal abdomen
A procedure performed to change the fetal presentation
• Internal– Podalic- changing the position of the
2nd twin after delivery of the 1st via vaginal manipulation
• External– Manual rotation of the fetus from
breech to cephalic presentation via external manipulation of the maternal abdomen
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External VersionExternal Version
Fig. 20-3
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Three MalpresentationsThree Malpresentations
1. Brow: forehead– C/S delivery
2. Face– Vaginal delivery
3. Breech• Frank – buttocks• Footling – foot/feet– C/S delivery
1. Brow: forehead– C/S delivery
2. Face– Vaginal delivery
3. Breech• Frank – buttocks• Footling – foot/feet– C/S delivery
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Obstetric Forceps Obstetric Forceps
Fig. 20-4 Middle row
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Obstetric Forceps (cont’d)Obstetric Forceps (cont’d)
Fig. 20-4 Last row
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Birth Assisted with a Vacuum ExtractorBirth Assisted with a Vacuum Extractor
Fig. 20-5
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Cephalo-pelvic DisproportionCPDCephalo-pelvic DisproportionCPD
Fetus is larger than the pelvic diameter
• Hallmark symptom is failure of the fetus to descendCauses: – diseases affecting bones (rickets),
injury– congenital anomolies, pelvic shape &
size
Fetus is larger than the pelvic diameter
• Hallmark symptom is failure of the fetus to descendCauses: – diseases affecting bones (rickets),
injury– congenital anomolies, pelvic shape &
size
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Cephalo-pelvic DisproportionCPDCephalo-pelvic DisproportionCPD
• Diagnosis– CT scan– Estimated fetal weight per US
• Trial of labor– Borderline pelvic diameter
• Support patient– Keep the patient informed of progress– Position changes: sitting squatting, hands
& knees may help with descent– Prepare for possible C/S
• Diagnosis– CT scan– Estimated fetal weight per US
• Trial of labor– Borderline pelvic diameter
• Support patient– Keep the patient informed of progress– Position changes: sitting squatting, hands
& knees may help with descent– Prepare for possible C/S
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Skin Incisions for Cesarean BirthSkin Incisions for Cesarean Birth
Fig. 20-8
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Uterine Incisions for Cesarean BirthUterine Incisions for Cesarean Birth
Fig. 20-9
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Vaginal Delivery After Cesarean Section - VBACVaginal Delivery After Cesarean Section - VBAC
Increased risk for uterine rupture
• Obtain informed consent• Nursing Implications
– Large bore IV access– Continuous EFM
Increased risk for uterine rupture
• Obtain informed consent• Nursing Implications
– Large bore IV access– Continuous EFM
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Premature Rupture of Membranes - PROMPremature Rupture of Membranes - PROM
Spontaneous rupture of membranes prior to the onset of labor
• Associated conditions:– Infection– Previous history of PROM– Hydramnios– Multiple pregnancy– UTI– Trauma
Spontaneous rupture of membranes prior to the onset of labor
• Associated conditions:– Infection– Previous history of PROM– Hydramnios– Multiple pregnancy– UTI– Trauma
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Premature Rupture of Membranes - PROMPremature Rupture of Membranes - PROM
• Determine time of PROM
• Verification of PROM: – Visualization– Sterile speculum exam– pH
• Determine time of PROM
• Verification of PROM: – Visualization– Sterile speculum exam– pH
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Premature Rupture of Membranes - PROMPremature Rupture of Membranes - PROM
• Nursing Assessment– Vital signs (temp q 2hr)– Fetal monitoring– Nature of fluid– WBC count
• Administration of Celestone - betamethasone– PPROM: preterm
• Nursing Assessment– Vital signs (temp q 2hr)– Fetal monitoring– Nature of fluid– WBC count
• Administration of Celestone - betamethasone– PPROM: preterm
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Preterm LaborPreterm Labor
Defined as: labor that occurs between 20 and 37 weeks gestation.
• Associated conditions– Multiple gestation– Hydraminos– UTI– Abdominal trauma– Infection– No prenatal care– Low socio-economic status
Defined as: labor that occurs between 20 and 37 weeks gestation.
• Associated conditions– Multiple gestation– Hydraminos– UTI– Abdominal trauma– Infection– No prenatal care– Low socio-economic status
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Preterm LaborPreterm Labor
• Fetal Fibronectin test– 99% accurate predictor of NO
preterm birth within 7 days
• Nursing Implications– Promote rest, hydration, circulation– Monitor FHR and uterine activity– Administer tocolytics as ordered
• Fetal Fibronectin test– 99% accurate predictor of NO
preterm birth within 7 days
• Nursing Implications– Promote rest, hydration, circulation– Monitor FHR and uterine activity– Administer tocolytics as ordered
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Preterm LaborPreterm Labor
TocolyticsTocolytics
• Medications prescribed to stop preterm labor– Terbutaline – B adrenergic receptor
antagonist– Magnesium sulfate – CNS depressant– Ritodrine - not FDA approved for PTL
rarely used.
TocolyticsTocolytics
• Medications prescribed to stop preterm labor– Terbutaline – B adrenergic receptor
antagonist– Magnesium sulfate – CNS depressant– Ritodrine - not FDA approved for PTL
rarely used.
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Tocolytic DrugsTocolytic Drugs
Smooth muscle relaxants
Terbutaline Contraindications: hold and notify HCP if maternal HR > 140bpm
• Side effects: increase heart rate, feeling of anxiety, headache, increased blood glucose
Magnesium Sulfate• Contraindications: discontinue for resp. depression,
magnesium level >8, administer ca+ gluconate
• Side Effects: flushing, headache, nausea, lethargy, dizziness, decreased DTR, decreased resp. rate, pulmonary edema
Smooth muscle relaxants
Terbutaline Contraindications: hold and notify HCP if maternal HR > 140bpm
• Side effects: increase heart rate, feeling of anxiety, headache, increased blood glucose
Magnesium Sulfate• Contraindications: discontinue for resp. depression,
magnesium level >8, administer ca+ gluconate
• Side Effects: flushing, headache, nausea, lethargy, dizziness, decreased DTR, decreased resp. rate, pulmonary edema
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Ruptured UterusRuptured Uterus
• Causes:– Long difficult labor– Injudicious use of Pitocin– Previous C/S
• Assessment Findings– Fetal bradycardia– Maternal abdominal pain
• Obstetrical Treatment– Emergency Cesarean Section delivery
• Causes:– Long difficult labor– Injudicious use of Pitocin– Previous C/S
• Assessment Findings– Fetal bradycardia– Maternal abdominal pain
• Obstetrical Treatment– Emergency Cesarean Section delivery
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Uterine RuptureUterine Rupture
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Prolapsed Umbilical CordProlapsed Umbilical CordOccurs when the umbilical cord precedes
the presenting part.• Primary Risk Factor
– Fetal head is not engaged or at a high station
Vessels carrying blood to & from the fetus are compressed, usually results in fetal distress or possible demise
• Nursing Interventions– Knee chest position– Administer O2– Manual lift of fetal head off the cord
Occurs when the umbilical cord precedes the presenting part.
• Primary Risk Factor– Fetal head is not engaged or at a high station
Vessels carrying blood to & from the fetus are compressed, usually results in fetal distress or possible demise
• Nursing Interventions– Knee chest position– Administer O2– Manual lift of fetal head off the cord
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Variations of Prolapsed Umbilical CordVariations of Prolapsed Umbilical Cord
Fig. 27-6a
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Variations of Prolapsed Umbilical Cord (cont’d)Variations of Prolapsed Umbilical Cord (cont’d)
Fig. 27-6c
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Amniotic Fluid EmbolismAmniotic Fluid EmbolismIn the presence of a small tear in the amnion
and chorion, a small amount of amniotic fluid may leak into the chorionic plate and enter the maternal blood system.
Can also occurs at areas of placental separation, cervical tears or during trumultuous labor
The more debris (meconium, vernix, lanugo) in the amnionic fluid, the greater the maternal problems caused by possible anaphylactic reaction to fetal antigens
In the presence of a small tear in the amnion and chorion, a small amount of amniotic fluid may leak into the chorionic plate and enter the maternal blood system.
Can also occurs at areas of placental separation, cervical tears or during trumultuous labor
The more debris (meconium, vernix, lanugo) in the amnionic fluid, the greater the maternal problems caused by possible anaphylactic reaction to fetal antigens
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Amniotic Fluid EmbolismAmniotic Fluid Embolism
Assessment Findings: Sudden onset• Respiratory distress (dyspnia)
• Circulatory collapse (cyanosis)
• Tachycardia
• Hypotension
• Acute hemorrhage
• Cor Pulmonale
• Frothy sputum
Assessment Findings: Sudden onset• Respiratory distress (dyspnia)
• Circulatory collapse (cyanosis)
• Tachycardia
• Hypotension
• Acute hemorrhage
• Cor Pulmonale
• Frothy sputum
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Amniotic Fluid EmbolismAmniotic Fluid Embolism
Obstetrical Emergency
• Interventions:– Large bore IV line– Positive pressure oxygen– CPR– Blood transfusion - DIC– Emergency C/S if pregnant
Prognosis – 50% of women die with the first hour of symptoms
Obstetrical Emergency
• Interventions:– Large bore IV line– Positive pressure oxygen– CPR– Blood transfusion - DIC– Emergency C/S if pregnant
Prognosis – 50% of women die with the first hour of symptoms