OB Ex2: Intrapartum Complications

Dytsocia, precipitous birth, and preterm labor, meds for PTL

Dystocia

Abnormal progression of labor → results in prolonged labor.

• May hear this called "failure to progress" 

• Leading cause of c-section in the U.S.

Prolonged labor may result in

• Maternal exhaustion 

• Maternal dehydration

• Infection for mom and baby

• Postpartum hemorrhage

• Perineal lacerations 

• Overall, more medical and surgical interventions

• Overall, increased mortality and morbidity for mom and baby

5 “P's”

• powers

• passageway

• passenger

• Psyche

• Position

Powers

Expulsive forces of labors; contractions and mom pushing.

The uterus may either never fully relax (hypertonic contractions), placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions.

Powers: Hypertonic Labor

• Etiology

  • ↑ frequency, ↓ strength & effectiveness

  • Can be very painful

  • usually seen in 1^st stage early phase

  • too many contractions = ↓ placental perfusion

• Treatment

  • SVE; is there cervical dilation, is labor proressing?

  • IV fluids

  • Pain management

  • DC medications/tocolytics (meds that stop contractions)

  • Assess other P’s

Powers: Hypotonic Labor

• Etiology

  • Weak, irregular, ineffective contractions

  • Mal positioned fetus 

  • Over-distended uterus, bowel, bladder

  • Excessive analgesia/anesthesia 

Treatment:

• Position changes

• Augmentation/AROM (Pitocin or breaking water)

• Assess other P’s

 Macrosomia

Larger than average baby; a cause of overdistended uterus

Polyhydramnios

Excessive/extra amniotic fluids; cause of overdistended uterus

Passageway problems

Bony pelvis, cervix, vagina, pelvis floor muscles 

• Cephalo-pelvic disproportion (CPD)

  • Pelvis too narrow or fetus too large

• If fetus can’t descend → fetal death, uterine rupture, shoulder dystocia

• Placenta Previa; placenta is covering the cervix = c-section

• Bowel/Bladder distension can make passageway smaller

• Uterine fibroids can get in the way

Passageway: Treatment

• Positioning; utilize different positions and stretches to help.

• Empty bowel/bladder = more space

• Vacuum/forceps; if baby is low enough in birth canal.

• Assess other P’s

• Trial of labor --> CS?

Passenger problems

The babyyyy

• Etiology

  • Fetal position; what position is baby in?

    • Mal-presentation

    • Occiput posterior = pressure on moms back/spine

  • Fetal size

    • Macrosomia = baby is larger than average

  • Shoulder dystocia = head is born but shoulders won’t fit through pelvis

  • Multifetal pregnancy = twinss

Passenger treatment

• Position changes

• Delivery interventions; vaccum, forceps

• Fetal monitoring; how is baby tolerating labor

• An external cephalic version (ECV) is a procedure that can be done in the hospital to manually repostion the baby (breech to vertex). It is usually performed between 36-38 weeks. 

Psyche problems

• Maternal exhaustion

• Nulliparity (first baby)

• Caffeine/substance abuse

• Hormone regulation; stress and anxiety hormones activate fight or flight = releases catecholamines = disrupts uterine contractions

• Support

Stress/Anxiety

Stress/anxiety hormones activate the sympathetic nervous system --> release of catecholamines ---> myometrial (uterine) dysfunction. Nori/epi lead to uncoordinated uterine activity, more fear/tension/pain, and decrease effective contractions.

Psyche Treatment

• Continuous support

• Control the environment

• Pain management (options, what do they want)

• Position changes (comfort)

• Education (remind them what their body is going through, what their options are in labor)

Precipitous Birth

The “Precip”. Things go very quickly, entire labor lasts less than 3 hours.

Possible complications:

• Cervical lacerations; the body may have not fully dilated before delivery

• Emotional distress; intense, quick labor

• Newborn trauma; at risk for bruising, intracranial hemorrhage bc came out too fast.

• Lack of preparedness - healthcare team

Preterm Labor

Regular uterine contractions that change the cervix prior to 37 weeks.

• Many long term side effects; neurodevelopmental disorders, respiratory distress syndrome, and infections

• these infants (preterm babys) are much more likely to be hospitalized throughout childhood.

Preterm Labor Management

• Tocolytics; drugs that stop contractions.

• Magnesium sulfate; Relaxes uterine muscles to stop irritability and contractions

• Corticosteroids; administered prior to 34 weeks for fetal lung maturity.

• Activity restrictions/Monitoring

  • Antepartum patients (bed rest)

Magnesium Sulfate

treats preterm labor and pre-eclampsia; relaxes uterine muscles and stops contractions.

• Ca antagonist (IV)

• Monitor VS, listen to lungs sounds bc can cause pulmonary edema

• Assess deep tendon reflexes; central nervous system depressant

• Assess LOC, I’s and O’s, and continuous FHR.

• Assess for magnesium toxicity: decreased LOC, slow RR and slow FHR, slurred speech, weakness, and respiratory\cardiac arrest.

  • Have calcium gluconate readily available for magnesium toxicity.

Common side effects

• hot, flushed, N/V, low BP and lethargy.

Betamethasone (Celestone)

Steroid that promotes fetal lung maturity

• Administer two doses intramuscularly 24 hours apart.

• Monitor for maternal infection or pulmonary edema, assess maternal lung sounds.

Indomethacin (Indocin)

NSAID; inhibits prostaglandins = inhibits uterine activity to slow/stop preterm labor.

• Monitor vitals signs, continuous fetal monitoring, may cause GI upset

• Contraindicated > 32 weeks gestation due to fetal heart complications, may close the ductus arteriosus 

Nifedipine (Procardia)

Blocks calcium movement into muscle cells, inhibits uterine activity to stop/slow preterm labor.

• PO

• Use caution with magnesium sulfate (Hypotension)report a pulse rate >110 bpm. Assess BP often.

• Continuous fetal monitoring

• Monitor for adverse effects, such as flushing of the skin, headache, transient tachycardia, palpitations, postural hypertension, peripheral edema, and transient fetal tachycardia.

• Contraindicated in women with cardiovascular disease or hemodynamic instability.

Terbutaline

β₂ adrenergic receptor agonist; helps prevent and slow contractions of the uterus.

• SQ, IV, & PO

• May see shaking, tachycardia, anxiety

• Monitor v/s

Preterm Labor risk factors

• Idiopathic

• African American race higher likelihood

• Age extremes <16 and >40

• Low SES 

• Alcohol, drug use, smoking

• Pre-existing DM or HTN

• Multiple pregnancy

• STI's, BV, UTI

• Hydramnios

• Cervical insufficiency

• Domestic violence

• Stress, acute & chronic

• Late or no prenatal care

Preterm Labor s/s

• Uterine contractions

• Menstrual-like cramps

• Low backache

• Pelvic pressure

• Intestinal cramps/ diarrhea

• ↑/change in vaginal discharge

• “Something is not right”

Contraindications to Stopping PTL

• Infection

• Fetal distress

• Oligohydramnios (not enough amniotic fluid)

• Maternal condition such as preeclampsia or vaginal bleeding, significant cervical dilation already

• Risks outweigh benefits