Labor and Delivery Complications

Premature (Pre-Labor) Rupture of Membranes (PROM)

- ROM prior to onset of labor

- most people start labor within 24hr of ROM

- prolonged ROM increases risk for chorioamniotitis

- not related to labor

Preterm Premature Rupture of Membranes (PPROM)

- ROM prior to 37 weeks gestation

- around 3% of pregnancies

- concerns include infection, cord prolapse, fetal malpresentation, precipitous labor

- usually no identifiable risk factors

- possible association with smoking, previous PPROM, infections, vaginal bleeding

PPROM Treatment

- betamethasone to promote fetal lung maturity

- monitor for infection

- antibiotic therapy if caused by infection

- limit vaginal exams

- fetal monitoring

- monitor for contractions

- modified bed rest

Preterm Labor

- contractions that cause cervical dilation between 20 and 36 6/7 weeks

- can be caused by maternal infection

Preterm Labor S/S

- irregular mild contractions

- menstrual-like cramping

- low back pain

- feelings of vaginal or pelvic pressure

- light bleeding or spotting

- bloody show

Preterm Labor Diagnosis

- cervical dilation

- positive fetal fibronectin test

Preterm Labor Treatment

- suppression of labor

- activity restriction

- hydration

- tocolytics

- corticosteroids

- antibiotics

Preterm Labor Medications

Indomethacin:

- contraindicated with maternal bleeding disorders, renal dysfunction, asthma, aspirin allergy

Nifedipine:

- contraindicated with maternal hypotension, drug allergy, certain cardiac conditions

Terbutaline:

- contraindicated with some cardiac disease, poorly controlled diabetes, placenta previa, placenta abruption

Magnesium sulfate:

- monitor RR, urine output, deep tendon reflexes, LOC

- calcium gluconate readily available

Chorioamnionitis Cause

- ascent of bacteria through cervix

Chorioamnionitis Risk Factors

- PROM

- PPROM

- vaginal exams

- prolonged labor

- preterm labor

Chorioamnionitis Maternal Complications

- sepsis

- postpartum hemorrhage

Chorioamnionitis Neonatal Complications

- sepsis

- perinatal death

- asphyxia

- cerebral palsy

- pneumonia

- meningitis

- intraventricular hemorrhage

- neurodevelopmental delay

Chorioamnionitis Diagnosis

- maternal fever of 39°C (102.2 F) once

- maternal fever of 38 °C (100.4 F) to 38.9 °C (102 F) twice, plus fetal/maternal tachycardia, uterine tenderness, foul-smelling discharge, elevated WBCs

Chorioamnionitis Treatment

- acetaminophen IV for fever

- broad spectrum antibiotics

- continued labor vs cesarean

Post-Term Pregnancy

- reached or exceeded 42 weeks

- risks include still birth, fetal macrosomia, dystocia, birth injury, operative birth, postpartum hemorrhage

- treatment includes expectant management or induction

Labor Induction

- oxytocin (pitocin) administered by IV

- starts at low rate and increased q30min

- may cause nausea, vomiting, headache, flushing, tachycardia, hypotension, arrhythmias, uterine tachysystole

- uterine tachysystole with nonreassuring FHR requires d/c pitocin

- nipple stimulation

Labor Induction Complications

- nonreassuring fetal heart tones

- stop pitocin and notify provider

- side-lying position

- fluid bolus

- O2 via nonrebreather

- terbutaline if tachysystole

- monitor FHR and contractions

- document response

- prep for emergency C/S

Labor Augmentation

Amniotomy:

- aritificial ROM

- risk for cord prolapse

- risk for chorioamnionitis

Pitocin:

- same admin guidelines as induction

Episiotomy

- surgical incision of posterior aspect of vulva

- used if high-risk for tear or for expedited birth from fetal compromise

- also used for more room for forceps, vacuum, shoulder dystocia

- risks include infection, bleeding, pain

Operative Vaginal Delivery

- forceps-assisted birth

- vacuum-assisted birth

Unplanned Cesarean Birth Indications

- failure to progress

- nonreassuring FHR

- fetal malpresentation

- umbilical cord prolapse

- uterine rupture

Planned Cesarean Birth Indications

- fetal macrosomia

- placenta previa

- active genital herpes outbreak

- previous C/S

Cesarean Complications

- bowel/bladder injury

- hemorrhage

- infection

- neonatal respiratory distress

Uterine Rupture Risk Factors

- congenital uterine abnormality

- uterine trauma, accident, or previous C/S

- overdistention of uterus due to LGA fetus, multifetal gestation, or polyhydramnios

- uterine tachysystole

- forceps-assisted birth

Uterine Rupture S/S

- sudden ripping, tearing, sharp pain

- abdominal pain, uterine tenderness

- nonreassuring fetal heart tones

- cessation of contractions

- manifestations of hypovolemic shock

Cord Prolapse

- umbilical cord precedes fetal head in birth canal

- first sign is FHR change, fetal bradycardia, variable decelerations

- obstetric emergency requiring C/S

- hold presenting part off cord

Amniotic Fluid Embolism

- amniotic fluid enters maternal circulation

- initial symptoms include respiratory failure and cardiac arrest

- if patient survives, at risk for hemorrhagic shock with disseminated intravascular coagulation

Amniotic Fluid Embolism Risk Factors

- placenta previa/abruption

- preeclampsia/eclampsia

- hypertensive disorders

- oxytocin administration

- DM

- C/S

- cervical ripening

- forceps-assisted birth

- uterine rupture

- cervical laceration

Amniotic Fluid Embolism Interventions

- CPR

- IV or IO access

- epinephrine

- norepinephrine for BP control

- dobutamine

- fast delivery of fetus

- manage DIC