Labor and Birth Complications

Dystocia

The abnormal progression of labor

What are some causes of dystocia?

Expulsive forces, fetal presentation and positioning, maternal pelvic structure, maternal fatigue and stress

What complications does dystocia increase the risk for?

Hemorrhage, infections, perineal lacerations, and anal sphincter injury

Hypertonic Uterine Dysfunction

Strong contraction but loss of downward pressure on the cervix. Usually stalls at >4cm. May be uncoordinated contractions

Hypotonic Uterine Dysfunction

Contractions decrease in strength and consistency. Labor stalls

Precipitous Labor

Abrupt onset of active labor quickly passing through the stages

Preterm Labor

Contractions resulting in some effacement and dilation between 20-37 weeks of gestation

Preterm Birth

Uterine contractions with cervical effacement and dilation between 20-37 weeks gestation, resulting in delivery

Tocolytics

Medications that promote uterine relaxation

What does the administration of magnesium sulfate do for the fetus?

Provides neuroprotection for the fetus, but only if given before 32 weeks

What do antenatal glucocortidoids do?

Stimulate fetal lung maturity by promoting release of enzymes that induce production or release of lung surfactant. Takes 48 hrs for optimal benefits

Magnesium Sulfate

CNS depressant that relaxes smooth muscle inhibiting uterine activity

Beta-Adrenergic Agonists/Beta-Mimetic (Terbutaline)

Relaxes smooth muscle, inhibiting uterine activity

Prostaglandin Synthetase Inhibitors (NSAIDs)

Inhibits prostaglandins and uterine activity

Calcium Channel Blockers (Nifedipine)

Blocks calcium entry into smooth muscle cells thus inhibiting uterine activity

Premature Rupture of Membranes (PROM)

Rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of labor at any gestational age

Preterm Premature Rupture of Membranes (PPROM)

Membrane rupture before 37 and 0 days of gestation

What is a major risk factor of PROM or PPROM?

Infection. Responsible for 1/3 of all preterm births

Chorioamnionitis

Bacterial infection of the amniotic cavity

What are signs and symptoms of Chorioamnionitis?

Maternal fever, fetal tachycardia, uterine tenderness, and foul amniotic fluid

Post-Term Pregnancy

A pregnancy that extends beyond the end of 42 weeks gestation with unknown etiology

What are the maternal risks of post-term pregnancy?

C-section, dystocia, birth trauma, postpartum hemorrhage, and infection

What are the fetal risks of post-term pregnancy?

Macrosomia, shoulder dystocia, brachial plexus injuries, low APGAR scores, postmaturity syndrome, and cephalopelvic disproportion

What is an intervention for breech presentation?

Versions (external cephalic or internal)

Induction of Labor

Stimulating contractions via medical or surgical means

Augmentation of Labor

Enhancing ineffective contractions after labor had begun

When should the induction of labor be performed?

Only when there is a clear medical indication for it and the expected benefits outweigh its potential harms

The Bishop Score

Rating system used to determine level of cervical inducibility. Assesses cervical dilation, effacement, consistency, position, and fetal station. Labor induction most likely to be successful with a higher score

Amniotomy

The artificial rupture of membranes through the use of an amnihook. May cause infection, fetal injury, or cord prolapse. Helps augment/induce labor

“Stripping Membranes”

Provider sweeps a gloved finger over the membrane that connects the amniotic sac to the wall of your uterus. May cause release of prostaglandins and start contractions. Accidental ROM is a risk

Elective Induction of Labor

Labor is initiated without a medical indication. Many are for the convenience of the woman or her primary health care provider. Elective induction of labor should not be initiated until the woman reaches 39 weeks of gestation

Oxytocin

Hormone normally produced by posterior pituitary gland that stimulate uterine contractions. Used to induce or augment labor. Client must be on the monitor to continuously assess FHR and contractions

Why is oxytocin a high risk medication?

It can cause placental abruption, uterine rupture, c-section, postpartum hemorrhage, infection, and fetal hypoxemia and acidemia

Uterine Tachysystole

More than five contractions in 10 minutes averaged over 30 minutes

Cytotec (Misprostol)

Prostaglandin that ripens the cervix, helping it dilate and efface. Tablet is cut into four and placed into the posterior vaginal fornix

What is the antidote for Cytotec (Misoprostol)?

Terbutaline

When can pitocin not be started?

Less than 4 hours after dose of misoprostol

Cervidil (Dinoprostone)

Vaginal insert (balloon) that softens the cervix. Can be removed when cervix is properly softened/dilated or at 12 hours (good for evening induction). Have the patient eat/void before use. Can be removed if effect is too strong.

What are two types of Operative Vaginal Births?

Vacuum Extractor or Forceps

What is the immediate post operative care for a c-section?

Fetal Care- Suctioning if needed, warmth, place on mother

Maternal- Labor/circulating nurse will follow into post op area

Trial Of Labor (TOL)

Observation of a woman and her fetus for a specified length of time to assess safety of vaginal birth

Vaginal Birth After C-Section (VBAC)

Used when indications for for cesarean birth are not likely to reoccur. Candidates must have had a transverse incision, only had 1 section, and must stay on the monitor due to the risk of uterine rupture

Shoulder Dystocia

Head is born, but anterior shoulder cannot pass under the pubic arch. Newborn is more likely to experience birth injuries related to asphyxia, brachial plexus damage, and fracture. Mother’s primary risk stems from excessive blood loss from uterine atony or rupture

Nursing Actions for Shoulder Dystocia

Call for help STAT. Empty patient’s bladder if possible. Pull woman’s legs back toward chest (McRobert’s Maneuver) or have her get on her hands and knees. Give suprapubic pressure. DO NOT GIVE FUNDAL PRESSURE.

Meconium Stained Amniotic Fluid

Indicates that the fetus has passed the first stool before birth. Places the infant at risk for meconium aspiration. Requires the team skilled in neonatal resuscitation.

Uterine Rupture

Scarred uterus from previous c-sections is the most common cause. May see abnormal FHR with sudden bradycardia, loss of fetal station, abdominal pain, and shock. Need an emergent birth

Amniotic Fluid Embolism

Amniotic fluid containing particles of debris gets into the maternal blood stream, and maternal body creates an allergic type response. (impossible to predict or prevent). Acute onset of hypotension, hypoxia, cardiovascular collapse, and coagulopathy. Maternal mortality to 60-80%. Neonatal outcome is poor