Complications

of
Labor and Delivery
Presented by
Jeanie Ward

Dystocia
An abnormal, long, or
difficult labor or delivery

Dysfunctional Labor is related to

Abnormalities of the Critical Factors:
PASSAGEWAY

PSYCHE

Critical
Factors

PASSENGER

POWERS

UTERINE DYSTOCIA
DYSFUNCTIONAL UTERINE CONTRACTIONS

HYPOTONIC UTERINE CONTRACTIONS

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

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

Friedmans Graph
Hypotonic Uterine Contractions
Normal
Curve

Prolonged active phase

Therapeutic Interventions
Ambulation
Nipple Stimulation --release of endogenous
Pitocin
Enema--warmth of enema may stimulate
contractions
Amniotomy--artificial rupture of the
membranes
Augmentation of labor with Pitocin

Amniotomy
Amniotomy is the artificial rupture of the amniotic
sac with a tool called the amniohook (a long
crochet type hook, with a pricked end) or an
amnicot (a glove with a small pricked end on one
finger).

One of these will be placed inside the vagina,

where the caregiver will rupture the amniotic sac
or membrane.

AMNIOTOMY
Advantages of doing this before Pitocin
Contractions are more similar to those of
spontaneous labor
Usually no risk of rupture of the uterus
Does not require as close surveillance

Disadvantages of an Amniotomy
Delivery must occur
Increase danger of prolapse of umbilical cord
Compression and molding of the fetal head (caput)

Amniotomy
Nursing Care:

# 1-Check the fetal heart tones

Assess color, odor, amount
Provide with perineal care
Monitor contractions
Check temperature every 2 hours

Answer

Cervical Ripening

Cervical Ripening
prostaglandin E2 Medications
Prepidil gel
Cervodil

Prostaglandin E1 Medication
Cytotec

Nursing Care
Monitor maternal vital signs, cervical dilatation and effacement
Monitor fetal status for presence of reassuring fetal heart rate
Remove medication if hyperstimulation occurs

Hyperstimulation
Remove the medication
Turn patient to side-lying position
Provide oxygen via face mask
Give Terbutaline

PITOCIN
Augmentation of Labor
Assess first to make sure CPD is not present,
then start procedure:
Give 10 units / 1000 cc. fluid and hang as a secondary
infusion, never as primary

Nursing Care:

Assess contractions--are they increasing but not tetanic

Assess dilation and effacement
Monitor vital signs and FHTs
Make sure no signs of hyperstimulation before
increasing dose

HYPERTONIC UTERINE
CONTRACTIONS
Most often occur in first-time mothers,
Primigravidas
Contractions are ineffectual, erratic,
uncoordinated, and of poor quality that
involve only a portion of the uterus
Increase in frequency of contractions, but
intensity is decreased, do not bring about
dilation and effacement of the cervix.

Signs and Symptoms

PAINFUL contractions RT uterine muscle
anoxia, causing constant cramping pain
Dilation and effacement of the cervix does not
occur.
Prolonged latent phase. Stay at 2 - 3 cm. dont
dilate as should
Fetal distress occurs early uterine resting
tone is high, decreasing placental perfusion.
Anxious and discouraged

Friedmans Graph
Hypertonic Uterine Contractions

Prolonged latent
phase

Relieve pain and promote

normal labor pattern

Treatment of Hypertonic
Uterine Contractions
Provide with COMFORT MEASURES
Warm shower
Mouth Care
Imagery
Music
Back rub, therapeutic touch

Mild sedation
Bedrest or position changes
Hydration
Tocolytics to reduce high uterine tone

Ineffective Maternal Pushing

Results from:
Incorrect pushing techniques
Fear of injury
Decreased urge to push
Maternal exhaustion

Treatment
Teaching

Fetal Size
Macrosomia
Infant weighs more than 8 lb. 13 oz.
Shoulder dystocia
McRoberts maneuver
Suprapubic pressure

Abnormal Presentation and

Positions
Malpositions:
Posterior position--usually mom complains of
back pain
Malpresentation
Brow Face -

Breech -

Transverse -

Problems of Passenger
Cephalopelvic Disproportion (CPD)
Large baby or small pelvis
Usually diagnosed when there is an arrest in
descent
Station remains the same
Multiple Fetus
Twins, triplets, etc.

Treatments for Complications of

the Passenger
Positioning hands and knees, lunge to side
Version -- alteration of fetal position by abdominal or
intrauterine manipulation
Amnioinfusion - infusion into the uterine cavity
Forceps -- low forceps or outlet forceps usually
applied after crowning
Vacuum extraction -- disk shaped cup placed over
vertex of head and vacuum applied.
Episiotomy - surgical incision to allow more room
Cesarean Delivery

External Version Procedure

A version is a procedure used to change the

position of the fetal presentation by abdominal
manipulation.

External Version Procedure

Criteria
Fetus is not engaged
A reactive NST
36+ weeks gestation

Contraindications
A complicated pregnancy
Multiple pregnancy
Non-reassuring FHR

Nursing Care
Administer terbutaline prior to start
Monitor maternal and fetal vital sign
Post assess for contractions and kick-counts

Episiotomy

Episiotomy
Factors that predispose:

Primigravida
Large baby, macrosomia
Posterior position of baby
Use of forceps or vacuum extractor

Preventive Measures
Perineal massage
Side-lying for expulsion
Gradual expulsion

Nursing Care
Provide comfort and patient teaching
After delivery- apply ice and assess site

Forceps-assisted Delivery

Used to shorten the second stage

of labor and assist the womans
pushing efforts.

Forceps-Assisted Delivery
Risks
Fetus
Facial edema or lacerations
Caput succedaneum or cephalohematoma
Maternal
Lacerations of birth canal
Perineal bleeding, bruising, edema

Nursing Care
Preventive measures to decrease need for forceps
Patient teaching
After assessment of newborn and assessment of womans perineum.

Vacuum Extraction

Vacuum Extraction
Used to shortening the second stage of labor
and delivery of the fetus
Risk
Cephalohematoma or caput succedaneum

Nursing Care
Keep woman and partner informed during the procedure
After assess newborn

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

VBAC
Vaginal Birth After Cesarean
A woman may be considered a candidate for a
VBAC if the following guidelines are met:

With previous C-section, had low transverse incision

Has an adequate pelvis (absence of pelvic dystocia)
A woman who had a previous VBAC
Hospital must be set up to perform an emergency
cesarean within 30 minutes.

Vertical

Low Transverse

Cesarean Birth
Nursing Care
Frequent monitoring of woman and fetus

Complication
Uterine rupture

Cephalopelvic Disportion (CPD)

Causes
Large baby or small pelvis
Usually diagnosed when there is an arrest in descent
Symptoms
Station remains the same does not descend
Treatment and Nursing Care
Usually do a cesarean delivery if cause is pelvis
Utilize other measures such as forceps, vacuum extraction,
episiotomy.

Explain

Prolonged Labor
Failure to Progress
A labor lasting more than 18 - 24 hours or fails to
make changes in dilation or effacement

Definition:

Cervical dilation -- Primigravida 1.2 cm / hr.

Multigravida 1.5 cm / hr
Descent 1 cm. / hr in primigravida and 2 cm./ hr.
in multigravida

 Etiology
CPD - Cephalo Pevlic Disportion
Malpresentation, malposition
Labor dysfunction

Therapeutic Interventions
depends on the cause
1. Provide comfort measures
2. Conservation of energy
3. Psychological support
4. Position changes

PRECIPITIOUS LABOR OR DELIVERY

Labor that last less than 3 hours
Unexpected fast delivery

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

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

Rapid Delivery
Delivery Outside Normal Setting
Everything is OUT OF CONTROL!
mom is frightened, angry, feels cheated

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

Premature Rupture of the Membranes

Definition:
Spontaneous rupture of the membranes

Etiology
Infections
- Incompetent cervix
Fetal abnormalities - Sexual Intercourse

Major risk - ascending intrauterine infection

Other risk -- Precipitation of labor

 Treatment and Nursing Care:

Wait and watch, bedrest, no intercourse
Assess time membranes ruptures and if
labor started
Check temperature frequently
Describe character of amniotic fluid
Check WBC
Provide psychological support

Accelerating Fetal Lung Maturity

Betamethasone (Celestone) or
dexamethasone(Decadron are given to stimulate
the lungs and accelerate fetal lung maturity
thereby decreasing chance of respiratory distress
syndrome.
Lasts for about 7 days and need to repeat/

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

Therapeutic Interventions
Drug Therapy
Tocolytics
Uses: Stop or arrest labor
Criteria for use, dont give if:
Patient is in Active labor, cervix has dilated to
4 cm. or more
Presence of Severe Pre-eclampsia
Fetal complications / Fetal demise
Hemorrhage is present
Ruptured membranes

TOCOLYTIC MEDICATIONS
-adrenergic agonist
Examples:
Yutopar (ritodrine) or Brethine (terbutaline sulfate)

SIDE EFFECTS or WARNING SIGNS:

Palpitations
Tachycardia - pulse ~120
Tremors, nervousness, restlessness
Headache, severe dizziness
Hyperglycemia
TOXIC EFFECTS - PULMONARY EDEMA
rales, crackles, dyspnea noted on routine
nursing chest assessment every shift

Tocolytic Drugs
Nursing Care:
Stop the medication
Start oxygen
Give ANTIDOTE: INDERAL

Tocolytic Medications
Magnesium Sulfate
Decreases frequency and intensity of uterine contractions
Given via IV infusion pump
Loading dose 4-6 g in 100 ml given over ~20 minutes
Maintenance dose 1-4 g per hour.

Side effects
Lethargy and weakness
Sweating, flushing,
N/V, headache, slurred speech

Toxic effects
Absences of reflexes
Respiratory depression

Tocolytic Medications
Calcium Channel Blocker
nifedipine
Decreases smooth muscle contraction by blocking
the slow calcium channels at cell surface.
Administration
Orally or sublingually

Side Effects
Hypotension, tachycardia
Facial flushing
Headache

Tocolytic Medications
prostaglandin synthesis inhibitor
indomethacin (Indocin)
Action
Inhibits prostaglandin synthesis thus reducing uterine
contractions. (Prostaglandins stimulate uterine
contractions)
Used for pregnancies <32 weeks gestation and not
given for more than 72 hours.
Not a widely used medication to treat preterm labor.

Self Care Measures

Rest
Drink plenty of fluids 2-3 quarts /day
Empty bladder every 2-3 hours when awake
Avoid lifting heavy objects
Avoid overexertion
Modify sexual activity

Preterm labor
NURSING CARE:
Teach how to take medication -- on time
Teach patient to check pulse, call Dr. if > 120
140 (dehydration increases contractions)
Teach to assess fetal movement daily, kick
counts
Drink 8-10 glasses of water per day
Monitor uterine activity -- Home monitoring -call dr. if has contractions
Decrease activity
Lie on side
Keep bladder empty

Accelerating Fetal Lung

Maturity
Betamethasone / Celestone -- provides
stressor to the lungs of the fetus to
stimulate production of surfactant
Effective if have 24 hours prior to delivery

Prolapse of Cord

Prolapse of the Umbilical Cord

Definition:
Prolapse of the umbilical cord thorough the cervical
canal along side of the presenting part
Etiology/ Risk Factor:
Occurs anytime the inlet is not occluded. Fetus is
not well engaged
GOAL:
RELIEVE THE PRESSURE ON THE CORD
SUPPORT MOTHER AND THE FAMILY

Prolapse of the Cord

NURSING CARE / Therapeutic Interventions:
#1 Get the Pressure off the Cord

place in trendelenberg or knee-chest position

OR

elevate part with sterile gloved hand

Warmed, sterile Normal Saline or RL is introduced

into the uterus through an intrauterine pressure
catheter (IUPC)

Amnioinfusion
Used to treat:
Oligohydramnios
Meconium-stained amniotic fluid
Cord compression and variable decelerations

Nursing Care

Assess maternal and fetal vital signs

Assess contractions
Provide comfort measures
Measure intake and output of the fluid

Nursing Care for

Prolapse of Umbilical Cord
Palpate FHTs, NEVER ATTEMPT TO
REPLACE CORD!
Give O2 per mask at 10 Liters
Cover exposed cord with sterile wet gauze
Stay with the patient and offer support

Amniotic Fluid Embolism

Escape of amniotic fluid into the maternal
circulation
usually enters maternal circulation
through open sinus at placental site
Usually fatal to the Mother
amniotic fluid contains debris, lanugo,
vernix, meconium, etc.

Amniotic Fluid Embolism

Signs and Symptoms:
dyspnea
chest pain
cyanosis
shock
Therapeutic Interventions:
Deliver the baby
Provide cardiovascular and respiratory
support to Mom

Ruptured Uterus
Spontaneous or traumatic rupture of the uterus
Etiology:

Rupture of a previous C-birth scar

Prolonged labor
Injudicious use of Pitocin -- overstimulation
Excessive manual pressure applied to the fundus during
delivery

Signs and Symptoms:

Sudden sharp abdominal pain, abdominal tenderness

Cessation of contractions
Absence of fetal heart tones
Shock

Therapeutic Interventions:
Deliver the baby ! / Cesarean Delivery

The stimulation of uterine contractions

before the spontaneous onset of labor, for
the purpose of accomplishing birth

Labor Readiness
Fetal Maturity
Cervical Readiness with utilization of the
PreLabor Status Evaluation Scoring System/
Bishops score
Assesses cervical dilatation, effacement, consistency,
position, and fetal station.
A score of 8-9 is favorable for induction
Cervix

Score

Score

Score

Score

Posterior

Midposition

Anterior

---

Consistency

Firm

Medium

Soft

---

Effacement(%)

0-30

40-50

60-70

>80

closed

1-2

3-4

>5

Position

Dilation(cm)

Methods of Inducing Labor

Stripping the Membranes
With a gloved finger, the amniotic membranes lying
against the lower uterine segment are separated. This
causes release of prostaglandins that stimulate uterine
contractions

Pitocin Infusion
The goal is to have contractions occurring every 2
minutes of good intensity with relaxation between.
Used for induction and augmentation.

Other Methods of Induction

Ambulation
Nipple Stimulation --release of endogenous
Pitocin
Enema--warmth of enema may stimulate
contractions
Herbs
Insertion of balloon catheter
Foley catheter with internal stylet is inserting into the os
of the cervix and the balloon is inflated with
sterile saline (~30 ml.)
Mechanical stimulation induces labor

The End

Polyhydramnios and oligohydramnios

Polyhydramnios excessive amniotic fluid usually >
2000 ml.
Associated with fetal GI anomalies and maternal diabetes
Treatment watch and do nothing unless becomes short of
breath and in pain then do an amniocentesis

Oligohydramnios scanty amniotic fluid usually

<500 ml.
Etiology unknown
Risks fetal adhesions and fetal malformations
Treatment - amnioinfusion