Intrapartum Obstetric Complication During the 2nd Stage of Labor

Shoulder Dystocia

• Emergency with the anterior shoulder stuck under the pubic symphysis.

• Turtle sign:

  • When the baby’s head is out, but goes back in because of the shoulder being stuck

• Interventions:

  • “McRobert’s Maneuver”

  • Apply suprapubic pressure to help release the shoulder from under the pelvic bone to deliver fetus.’

Brachial Plexus Injury

• Severe Complication

• Fractured clavicle

• Could lead to nerve damage

  • No movement

  • No feeling

  • Most serious complication

Assisted Delivery Devices (Operative Vaginal Birth)

• Forceps & Vacuum Extractor & Kiwi device

C-Section Types of Incisions

• Low Vertical Incision

  • Common for emergencies

• High Vertical Incision

  • Common for emergencies

• Low Transverse Incision

  • Not typically for emergencies

  • Vaginal birth is not as risky after having this incision

• Risky to have a vaginal birth after already have C-section birth

  • Risk of rupture

Administration of Oxytocin Post Delivery

• 30-min bolus given between delivery of the anterior shoulder and the placenta, then maintenance rate for several hours

• Increases uterine contractions to help reduce blood loss and decrease the risk of post-partum hemorrhage

• Contractions cause uterine wall blood vessels to contract and decrease bleeding

• Increases afterbirth pains

• oxytocin administration

  • oxytocin 20 units, IM

  • 20 units in 500 mL NS / LR

• Induces contraction post-delivery to close off blood vessels to decrease bleeding

Nursing Care 3rd Stage (Delivery of the Placenta)

• May take 5-30 minutes to delivery

• Assessments during and after delivery of placenta

  • Gush of dark red blood

  • Umbilical cord lengthening

  • Firm fundus

• Examination of the placenta:

• Nurse must do this after the placental bowl is handed off from the provider-ensures a second look to be sure there are no missing fragments

• Umbilical cord lengthening is a sign that the placenta is coming off the wall & coming out

• Leading cause of post-partum hemorrhage is retained placenta fragments

• One little piece can cause bleeding

• Arm is reaching to scrape the wall to ensure no placenta fragments are left in there

Cord Blood Testing

• Rh- and O+ moms

  • RhoGAM

• Blood gases

• Infection (blood cultures)

• Fetal hypoxia (acidosis)

• Drug screening

4th Stage Restoration (Right after delivery for 1-4 hrs)

• Unhurried, uninterrupted bonding of mother and baby

• Initial attachment to the newborn

• Patient is excited and awake

• Provide comfort-:

  • Warm blankets

    • hot/cold beverages

      • ice pack to perineum (prevents hematoma)

• Assess Bleeding and bladder distention

  • Can impact firmness of the fundus

  • Contractions necessary to stop/minimize bleeding

Assess the Perineum & Fundus

• If the fundus is firm and there is bright red, trickling blood =  laceration

• If the fundus is not firm: “boggy”

  • Bright red flowing blood is not normal = uterine atony

  • Dark blood with clots is not normal =  retained placenta

• If boggy:

  • “massage the fundus” – using a BI-MANUAL approach.

  • One hand on the pelvic bone and one at the top of the fundus while massaging it.

APGAR

• Appearance

• Pulse

• Grimace

• Activity

• Respirations

• 1 minute to 5 minute