Intrapartum Complications

Dystocia

• Long, difficult or abnormal labor

• RF

  • Dysfunctional labor

  • Body build: 30+ lbs overwt; short

  • Uterine abnormalities

  • Malpresentation or CPD

  • Over stimulation w/ oxytocin

  • Maternal fatigue and fear

  • Epidural analgesia

• Suspect when cervical dilation not progressing, fetal descent not progressing and or uterine contractions ineffective

• Can be associated w/ maternal dehydration, exhaustion, risk of infection, fetal distress,

Problem w/ the powers

• Hypertonic uterine dysfunction

  • Painful contractions, uncoordinated, and frequent

  • Occur in latent phase (2-3 CM)

  • Common in 1st pregnancy and anxious moms

  • Manage: rest, analgesia to reduce pain and encourage sleep

• Hypotonic uterine dysfunction

• Precipitate Labor: labor completed in less than 3 hrs from onset of true labor to delivery of infant

• Risk for: fetal hypoxia, intracranial hemorrhage, lacerations

• Abnormal patterns

Problems w/ passenger

• Comps: asphyxia, injury or fracture, maternal lacerations

• Fetal causes:

  • Anomalies: mylomeningocele, hyrdocephalus, CPD, macrosomia

  • Malposition: OP, OT

  • Malpresentation: Breech

    • Face/brow: the diameter of the presenting part is larger than a vertex or occiput presentation—CS safest route

  • Multifetal pregnancy

  • Occiput Posterior or transverse

    • Sunny side up, second stage is prolonged, severe back pain

    • Risk of prolapsed cord if ROM early in labor

  • Breach: head is not down to serve as a wedge to dilate cervix

Shoulder dystocia

• Nursing Intervention

  • Increase diameter of birth canal and assist w/ the rotation of the anterior shoulder under the symphysis pubis

  • Suprapubic pressure: direct pressure applied downward immediately above the symphysis attempting to rotate the anterior shoulder

  • Note time of delivery of head and anterior/posterior shoulder

  • Prepare for resuscitation of infant

  • Examine infant for fractured clavicles and movement and tone of upper extremities

• HELPERR

  • Call for help

  • Eval for Epistiotomy (cutting vag to widen it)

  • Legs: McRoberts Maneuvar (knees all the way to the chest)

  • External PRessure—suprapubic

  • Enter: rotational maneuvers

  • Remove the posterior arm

  • Roll the pt to her hands and knees

Problems w/ the passageway

• Pelvic factors

  • Reduced capacity of the bony pelvis

  • Adolescents at risk due to immature pelvic size

  • Pelvic trauma?

• Soft tissue factors

  • Placenta previa

  • Uterine fibroids in lower segment

  • Full bladder or rectum

Problems w/ the psyche

• Tense muscles can result in less effective contractions

• Help mom relax

• Fear of pain

• No support

• Embarrassment

• Violation of religious rituals

Preterm Comps

• PROM

  • Broken water before onset of labor—after 37 wks tho

  • Infection is greatest risk

  • Labor will likely be induced

• PPROM

  • Broken water before 37 wks

  • Infection major risk

  • No unsterile digital clerical exams until in active labor

  • Manage fetal lung inmaturity

  • Assess: RF, s/s of labor, FHR, amniotic fluid characteristics

  • Antibiotics, Tocolytics, Glucocorticoids

  • Discharge home if no labor within 48 hrs

• Chorioamnionitis

  • CM: Maternal fever, fetal tachycardia, uterine tenderness, foul odor

  • Tx: IV broad spectrum antibiotics, delivery

Preterm RF

• Demographic

  • low soco status

  • unmarried

  • low Ed level

• Biophysical

  • previous preterm/postterm baby

  • Second trimester spontaneous AB

  • Being short or <100 lbs

  • DM, HTN, anemia, low progesterone

  • short intervals between pregnancies

• Biophysical in current pregnancy

  • Twins, bleeding, placenta probs, infection, gestational HTN

• Behavioral and psycho social

  • Smoking, poor nutriton, alcohol, substance abuse, inability to rest, inadequate prenatal care

Preterm Labor

• S/S:

  • Cramping/Contractions

  • Suprapubic pain or pressure

  • Urinary Frequency

  • Vaginal discharge

  • ROM

• Major diagnostic criteria

  • Gestational age

  • Uterine activity (contractions)

  • Progressive cervical change

• Testing

  • Endocervical length (shortened cervox <30 mm)

  • Fetal Fibronectin

    • Appearing between 24-34 wks

    • It’s the glue that helps attach the membranes to the lower part of the uterus

  • Salivary Estriol

    • Form of estrogen produced by placenta

    • 3-5 wks before labor Estriol in placenta increases dramatically

• Care

  • Bedrest

  • Tocolytics (stops contractions)

    • Terbutaline (Brethine)

    • Mag Sulfae

    • Indomethacin (Indocin)

    • Nifedipine (Procardia)

  • Glucocorticoids (matures baby lungs) (monitor mom BS)

  • Note frequency and intensity of contractions

  • Monitor I/O

  • 1500-2500 mL fluid restriction

  • Assess heart and lung sounds and DTRs

  • Monitor FHR

Postterm Pregnancies

• Baby has a long lean body, long finger nails, pealing skin

• Risks:

  • MOM: trauma, PPH (hemorrhage), CS, MAB (missed abortion)

  • Fetal: Dystocia, trauma, decreased perfusion

• Management:

  • Daily kick counts, BPP, NST, Induction

Induction/Augmentation

• Induction: chemical initiation of contractions before spontaneous onset

• Augmentation: initiation of oxytocin to improve contraction effectiveness

• Reasons: gestational HTN, DM, postdates, IUGR, hx of rapid labor and mother lives a distance from hospital, IUFD (intrauterine fetal death)

• Bishop Score: Evals readiness for induction; want score of 8 or more to have successful induction

• Methods: Foley Cath, oils/herbs, sex, acupuncture, enema, amniotomy, oxytocin

Cervical Ripening Methods

• Prostaglandin

  • Modified Trendelenburg for 30 min-1 hr after

  • Can cause hypotension

• Mechanical Dilators/Ballon caths

• Dilators that expand as they absorb fluid

AROM

• Artificial rupture of membranes or amniotomy or stripping of membranes

• Induces/arguments labor if progress begins to slow

• Nursing Interventions

  • Assess color, odor & consistency of fluid

  • Record time

  • Assess FHR before and immediately afterward

  • Assess temp at least every 2 hrs

  • Monitor signs of infection

  • Presenting part should be engaged to reduce risk of cord Prolapse

  • No HSV (Herpes)

• Prolonged rupture can lead to infection

  • Tachycardia, uterine tenderness, foul smelling discharge

  • Change pad frequently and perineal cleansing

Oxytocin Infusion

• Admin

  • Always IVPB

  • Given in milliunits

    • Started at 0.5-2.0 mu/min

    • Titrated to establish contraction pattern

  • Max dose is 20 mu/units

  • Requires continuous EFM of FHR

• Contra

  • CPD (cephlapelvic disproportion; baby head too big)

  • Non-reassuring fetal heart rate patterns

  • Placenta Previa or vasa Previa

  • Prior classical uterine incision or uterine surgery

  • Active genital herpes infection

• When to closely supervise

  • Multiples

  • Breech

  • Presenting part above the pelvic inlet

  • Abnormal FHR pattern not requiring emergency birth

  • Poly

  • Grand multiparity (had like 5+ kids)

  • Maternal cardiac disease, HTN

• Used to induce/augment

• Hyper stimulation of uterus with resulting blood flow to placenta causes fetal Compromise

• Pressure is elevated, I/O, Tetanic Contractins

• Oxygen decrease in fetus, Cardiac arrhythmia, irregularity in FHR, N/V

Intervention for Hyperstimulation

• W/ non-reassuring FHR: tachy or brady, marked or minimal to no variability

  • Side lying

  • Turn off oxy

  • Increase mainline IV rate

  • Start O2 per face mask at 8-10 L

  • Notify Dr

  • IUPC w/ severe variable decels, ROM, thick meconium, oli

Obstetrical Emergencies

• Prolapsed Cord

  • Cord lies below presenting part of fetus

  • Risk: long cord, floating or unengaged presenting part, breech

  • S/S: fetal bradycardia w variable decels, cord is seen or felt in or protruding from the vagina

  • Interventions:

    • Call for help

    • Trendelenburg, knee chest or hips elevated

    • Do not remove fingers from cord and vagina, holding the fetal presenting part off cord and feel for pulse

    • Tell Dr

    • Prepare for immediate delivery, usually CS

• Ruptured Uterus

  • Common cause is separation of the scare from previous c-section

  • Causes: intense contractions, induction w/ oxy, over distended uterus (twins), uterine trauma, previous C section, prolonged labor

  • S/S: Silent or dramatic, non-reassuring HR, signs of shock, sudden sharp pain, bandl’s ring (dent in stomach)

  • Care: Prevention, MAB, emergent CS

    • Possible laparotomy and repair, hysterectomy and blood transfusion

• Amniotic Fluid Embolism

  • Amniotic fluid enters mom circulation obstructing pulmonary vessels=resp distress and circulatory collapse

  • S/S: resp distress, circulatory collapse (shock), hemorrhage

  • Interventions:

    • Call for help

    • Oxygenate

    • Maintain cardiac output and replace fluid losses

    • Monitor fetal and maternal status

    • Prepare for emergency birth once stable

    • Provide emotional support

Mechanically Assisted Births

• Help guide baby head through birth canal and out of body

• Forceps or Vaccum (most common)

• Indications: fetal distress, certain types of abnormal presentation, arrest of rotation, assist w/ delivery of the head after breech delivery of the body

• Criteria: full dilation, known fetal part presenting, presenting part engaged, membranes ruptured, bladder empty, informed Consent, adequate anesthesia

• Types of delivery:

  • Outlet: scalp visible

  • Low: head is at +2 station

  • Mid: head is engaged. 0 station at least. Dangerous

• Interventions:

  • Monitor FHR

  • Empty bladder & pain control

  • Explain process & provide support

  • Vaccum

    • document pressure

    • pop-offs

  • Newborn

    • Assess Newborn for signs of trauma

C-Section

• Indication

  • Abnormal FHR

  • CPD (big head baby)

  • Malpresentation (breech)

  • Placental conditions (Previa or Abruption)

  • Cord prolapse

  • Dysfunctional labor pattern

  • Multiples

• Care

  • 18 g needle

  • Foley cath

  • Monitor mom and baby

  • Left wedge to displace wt of mother’s body off vena cava to perfuse uterus

  • Neonatal resuscitation

• Incisions

  • Important to identify the type of incision on the uterus

  • Horizontal provides stronger healed incision

  • Vertical is high risk of uterine rupture

• Anesthesia

  • General used in emergency

    • Risk of aspiration

    • Med crosses placenta in 2-3 mins

    • Delivery must happen quick

  • Regional

    • Low risk of aspiration

• Comps

  • Mom

    • Aspiration, Infection, Dehiscence, Hemorrhage, UTI, Organ injury

  • Newborn

    • Risk of prematurity if gestational age not calculated properly, resp distress, trauma

Vaginal Birth after C-section

• Candidates

  • Low cervical transverse uterine incision

  • Adequate pelvis

  • No other uterine scars or previous ruptures

• Interventions

  • Continuos fetal and uterine monitoring

  • IV access

  • Support and comfort measures

  • Care for labor

• Contra

  • Previous classical C section scar

  • Evidence of CPD (big headed baby)