NURS 333 Chapter 22 Complications Occurring During Labor & Delivery

Preterm labor

onset of labor before 37 weeks (ATI = 36.6 weeks)

Dystocia

labor with abnormally fast or slow progression

Second Stage of Labor

What?

Ineffective pushing by the mother

When?

Frequently used in women with epidurals

Maternal exhaustion

How?

Failure of the fetus to advance its station

Precipitous labor

labor that lasts 3 hours or less

Prolonged latent phase

labor lasting > 20 hours in a nulliparous women and > than 14 hours in multiparous women

Arrest of active phase

no cervical has occurred in 4 hours with adequate contractions

no cervical has occurred in 6 hours with inadequate contractions

Group B Streptococcus (GBS)

What organism colonizes the urogenital tract and is known as Group B Streptococcus (GBS)?

Benign except in pregnancy

Is Group B Streptococcus (GBS) benign in pregnancy?

Harm to the neonate

What harm can Group B Streptococcus (GBS) cause?

80%

By what percentage does treatment reduce GBS disease in neonates?

Reduces neonatal death

What effect does treatment have on neonatal death related to GBS?

Asymptomatic

What is the typical symptom presentation for Group B Streptococcus (GBS)?

35 to 37 weeks gestation (36 weeks gestation)

When does the CDC recommend GBS culture screening during pregnancy?

GBS + Urine or previously delivered GBS + infant with 1-week after birth

What are the treatment criteria for GBS?

Penicillin

What is the antibiotic of choice for treating Group B Streptococcus (GBS)?

At the onset of active labor or ROM and then every 4 hours until delivered

When should the loading dose of Penicillin be given during labor?

At least 4 hours before delivery

How long before delivery must Penicillin be started?

Ampicillin or Vancomycin

What should be given to patients allergic to Penicillin?

Antibiotic prophylaxis regardless of prior screening

What should be initiated for all preterm labor patients regarding GBS?

Five Ps of Labor

power

refers to uterine contractions and pushing efforts

Passageway

refers to the maternal bony pelvis and soft tissues.

Passenger

refers to fetal factors.

Psyche

refers to maternal state of mind

Anxiety can have a negative impact on normal labor progress and fetal outcomes.

The nurse may play a role in labor support.

Position

refers to maternal position.

Upright positions such as sitting, kneeling, squatting, or standing can shorten the first stage of labor by 90 minutes

Hypotonic Uterine Dysfunction

A condition where uterine contractions are either too uncoordinated or too weak to effectively dilate the cervix.

Occurs in the active phase of labor and is related to polyhydramnios, macrosomia, or multiple pregnancy.

Abdomen is soft when palpated during a contraction

Contractions: less than 3 to 4 every 10 minutes period and last < than 50

Risk factors for Hypotonic Uterine Dysfunction

premature rupture of membranes, fetopelvic disproportion, fetal malposition, overstretching of the uterus caused by a large newborn, multifetal gestation, or excessive maternal anxiety

IUPC

Amniotomy/AROM

Hypotonic Uterine Dysfunction Nursing Considerations

Continue to Monitor for Changes in the patient

Assess pain level

IUPC

Analyze contraction pattern (frequency, duration, and intensity)

Intensity: Montevideo Units > 200 MVUs +adequate contractions

AROM/Amniotomy

Check for prolapsed cord

Assess FHR***

Nursing Considerations/Interventions for Dystocia

Laboring down: a process of allowing the primary powers to facilitate fetal descent in the second stage.

Pushing resumes when the woman feels the urge to bear down.

Consult with OB or anesthesia to turn down or off the epidural

Bandl's ring

Cephalopelvic disproportion (CPD)

Mismatch between the size of the fetal head and the size of the maternal pelvis.

Malpresentation

Fetal position in relation to the maternal pelvis can impact labor progress is not optimal

(OP) Occiput Posterior

Most common

OP position often causes low back pain for women in labor

Longer duration of labor

Breech presentation

Occurs in 1 of 33 births.

Various types of breech presentations

are often diagnosed by Leopold's maneuvers and confirmed by ultrasound visualization.

Why are we concerned?

Asphyxia

Birth trauma

Increased risk for delivery by cesarean.

External cephalic version (ECV)

External rotation of the fetus to the head down (cephalic) position

Attempted after 36 weeks

Done under ultrasound guidance

Shoulder Dystocia

Impacted shoulder above or behind the symphysis pubis

Occurs more often in large fetuses

Turtle sign

Nursing Considerations

Call for help

Lower the HOB

McRobert's maneuver

Suprapubic pressure

Documentation

Other maneuvers to consider:

Gaskins maneuver

Zavenelli maneuver

Turtle sign

first sign of a shoulder dystocia

McRoberts maneuver

Pull knees to head to open up pelvis.

Episiotomy

is a surgical incision of the posterior aspect of the vulva made during the second stage of labor

is used if the patient is at high risk for a third- or fourth-degree perineal tear or if an expedited delivery is needed because of fetal compromise.

Risks include infection, bleeding, and pain.

Vacuum-assisted birth

is a device that applies suction to the fetal head to aid in extraction.

Cesarean deliveries are performed after three sets of pulls (traction) or a total application time of 15 to 30 minutes.

Forceps-assisted birth

are applied to either side of the fetal head to allow the provider to pull with contractions.

Cesarean deliveries are performed if it is difficult to apply forceps safely or delivery does not occur within 15 to 20 minutes.

False

Is the following statement true or false?

After an unsuccessful delivery using forceps, the provider will likely attempt a vacuum-assisted delivery.

Cord prolapse

Condition where umbilical cord precedes fetal head in the birth canal.

Obstetric emergency

How?

FHR tracing/pattern

Severe Bradycardia

Variable deceleration

Causes of cord prolapse

High station

Small or preterm fetus

Malposition of the fetus

Polyhydraminios

The cord should be handled as little as possible to prevent spasm of the umbilical artery.

What do I do as the nurse for cord prolapse?

Cesarean Birth

Cesarean section rate 32% in the United States

Maternal Complications

Bowel and bladder injury during surgery,

Hemorrhage,

Amniotic fluid embolism

Infection

Neonatal complication

Respiratory distress

Indications for cesarean delivery

Failure to progress

Nonreassuring fetal heart rate

Fetal malpresentation

Umbilical cord prolapse

Fetal macrosomia

C. Previous cesarean birth with a vertical uterine incision.

After reviewing a patient's prenatal record, the nurse determines which of the following is a contraindication for vaginal birth after cesarean?

A. Nonreassuring fetal heart rate

B. Previous cesarean birth due to a breech presentation

C. Previous cesarean birth with a vertical uterine incision

D. Occiput anterior fetal presentation

Unplanned cesarean deliveries

may cause women a sense of frustration, disappointment, even failure.

uterine rupture

tear in the uterine lining secondary to increased pressure

Risk factors

Prior uterine surgery

More common in C sections

Trial of labor after cesarean (TOLAC).

Signs

Sudden development of a category II or category III fetal heart rate pattern

Weakening contraction

Symptom

Abdominal pain

Amniotic embolism

referred to as anaphylactoid syndrome of pregnancy, may occur in pregnancy, labor, delivery, and the immediate postpartum period.

is caused when amniotic fluid enters maternal circulation and is associated with a maternal mortality rate of 32%.

Initial symptoms include respiratory failure and cardiac arrest.

If the patient survives an amniotic fluid embolism, she is at risk for hemorrhagic shock with disseminated intravascular coagulation.

Perinatal Loss

Stillbirth occurs in approximately 6 of 1,000 pregnancies that reach 20 weeks of gestation.

Risk is higher for adolescents, women over 35 years old, women of African descent, multifetal gestations, congenital anomalies, and maternal disease.

Prevention of perinatal loss may include:

Taking folic acid before and during pregnancy.

Routine syphilis screening and treatment.

Screening for and treating hypertensive disorders and maternal diabetes.

Access to emergency obstetric care.

Families who experience perinatal loss may experience anxiety, depression, or posttraumatic stress disorder.

D. All of the above.

Ms. Smith delivered 1 hour ago and suddenly experiences cardiac arrest. What should the nurse do next?

A. Call for help.

B. Open airway and assess breathing.

C. Initiate CPR.

D. All of the above.

treatment for uterine rupture

Cesarean delivery

Hysterectomy

A. Call for help.

Ms. Smith delivered 1 hour ago and suddenly experiences cardiac arrest. What is the priority action for the nurse?

A. Call for help.

B. Open airway and assess breathing.

C. Initiate CPR.

D. All of the above.

1. Frequency of contractions, how long, when the contractions started, pain assessment

2. Get fetal heart rate, cervical exam, take vitals, ask to empty bladder

Mary Smith is a 36yo G2P0010. Her LMP was April 25, 2021. Her EDC is _______. Ms. Smith is 39 weeks twin gestation. She presents to the triage complaining of contractions. Both fetuses are vertex/vertex.

What information would you want to find out from the patient?

What would be you next nursing action?

Ms. Smith most likely ruptured her membrane

Ms. Smith reports her pain is an 8 out 10 with each contraction. Her breathing is becoming more labored. She is profusely sweating. She is unable to talk through the contractions. But she also states she fells like she wet herself.