Week 6 -- Labor Complications

Labor, Complications, and Obstetrical Emergencies

Week 6

Instructor: Professor Ureno, MSN, RNC-MNN

Objectives

• Therapeutic Procedures: Describe methods to assist with labor and delivery.

• Obstetrical Emergencies: Identify key emergencies and related medical/nursing care.

• Dystocia: Describe primary causes and related nursing/medical care.

• Induction of Labor: Understand knowledge related to the induction and augmentation of labor.

• Childbirth Preparation: Identify key components for expectant families.

• Standards of Practice: Explain standards in maternity nursing.

• Legal Issues: Describe legal issues in maternity nursing.

Medications for Labor

• Prostaglandin E Analog: Misoprostol (Cytotec)

• Synthetic Prostaglandin: Dinoprostone (Cervidil, Prepidil)

• Penicillin: Amoxicillin (Amoxil)

• General Anesthesia/Opioid: Fentanyl (Duragesic)

• Hemabate

Complications of Labor and Birth (Chapter 10)

Dystocia

• Definition: Failure to progress, characterized by abnormally long labor.

• Causes:

  • Powers: Uterine contractions and maternal factors.

  • Passenger: Fetal factors and positioning.

  • Passage: Pelvic factors.

• Risk Factors: Congenital abnormalities, malpresentation (OP, face), cephalopelvic disproportion, maternal fatigue/dehydration, and fear.

Hypertonic Uterine Dysfunction

• Definition: Uncoordinated or hyperactive uterine activity resulting in ineffective contractions.

• Risk Factors: Nulliparous women.

• Assessment Findings:

  • Inadequate relaxation between contractions.

  • Painful and frequent contractions with little to no cervical change.

• Medical Management: Evaluate progress, improve perfusion.

• Nursing Actions: SVE, fluids, assess FHR, promote rest, pain medications, communicate with MD.

Hypotonic Uterine Dysfunction

• Definition: Insufficient uterine contractions with pressure less than 25 mm Hg.

• Risk Factors: Multiparous women, catecholamine release due to fear.

• Assessment Findings: Decreased frequency and strength of contractions.

• Medical Management: Evaluate labor progress, intervene if necessary (augment with pitocin).

• Nursing Actions: SVE, IV fluids, assess strip, promote ambulation, administer pitocin per order.

Precipitous Labor

• Definition: Labor lasting less than 3 hours from onset to birth.

• Risk Factors: Grand multipara, history of precipitous delivery.

• Assessment Findings: Hypertonic, long, strong contractions; possible cat II or III, rapid dilation.

• Medical Management: Prepare for birth.

• Nursing Actions: Stay in the room, monitor strip every 15 minutes, SVE, support client/family, anticipate PPH and lacerations, assess newborn for CNS depression/hypoxia.

Fetal Dystocia

• Causes: Excessive fetal size, malpresentation, multifetal pregnancy, fetal anomalies.

• Risk Factors: Abnormal presentation (breech), fetal anomalies, macrosomia.

• Assessment Findings: FHR above umbilicus, SVE reveals presenting part not engaged.

• Medical Management: Confirm position via SVE/ultrasound, determine delivery method (vacuum, C/S).

• Nursing Actions: Perform Leopold's maneuvers, assess FHR location, and SVE for presenting part.

Pelvic Dystocia

• Definition: Contraction of one or more pelvic planes.

• Contraction Types:

  • Inlet contraction: too small at the widest part.

  • Mid-pelvis contraction: narrow sacrosciatic notch.

  • Outlet contraction: anteroposterior diameter insufficient.

• Risk Factors: Small pelvis or abnormal shape.

• Assessment Findings: Delay in head descent.

• Medical Management: Evaluate pelvis and fetal descent.

• Nursing Actions: SVE, check station.

Cephalopelvic Disproportion (CPD)

• Definition: Baby's head is too large for the mother's pelvis.

• Factors Contributing to CPD: Fetal size, presentation, maternal pelvis size/shape, uterine contraction quality.

• Management: Often requires cesarean delivery.

Labor Interventions

• Discuss the reasons for induction or augmentation.

• Majority of labor begins spontaneously at term (37-42 weeks).

• Shift from natural to medicalized management has increased labor interventions.

Labor Induction

• Definition: Deliberate stimulation of contractions before the onset of labor.

• Criteria: Assess gestational age, cervical status, fetal size/presentation.

• Nursing Actions: Obtain informed consent, document indications, monitor FHR, adjust meds as needed.

• Indications: Post-date, IUFD, gestational hypertension, PROM, GDM, IUGR, chorioamnionitis, oligohydramnios.

• Contraindications: Vasa previa, malpositioned fetus, previous classical C/S, active HSV infection.

Oxytocin Induction

• Common Induction Agent: Pitocin.

• Goal: Establish UC pattern promoting cervical dilation (1cm/hr).

• Administration: Start at 1-2 mu/hour, adjust based on contraction patterns.

• Special Cautions: Multiple gestation, breech presentation, abnormal FHR.

Tachysystole

• Definition: More than 5 UCs in 10 minutes, continuous contractions without sufficient rest.

• Nursing Actions:

  • CAT I: Reposition mother, provide O2, IV fluids.

  • CAT II or III: Discontinue pitocin, call MD, reposition, and provide O2/IV fluids.

Bishop Score

• Scoring:

  • 8 or greater: higher chance of successful vaginal delivery (SVD).

  • 6 or less: may require cervical ripening to increase chance of SVD.

Cervical Ripening

• Definition: Softening and opening of cervix for labor.

• Methods:

  • Mechanical: Laminaria, balloon catheters.

  • Pharmacological: Misoprostol, Dinoprostone, membrane sweep.

Amniotomy

• Definition: Artificial rupture of membranes used to induce/augment labor.

• Contraindications: Fetal head not engaged, infection.

• Risks: Variable decels, bleeding, umbilical cord prolapse, infection.

• Nursing Actions: Assess FHR and amniotic fluid after procedure.

Labor Augmentation

• Definition: Increasing frequency and efficacy of existing contractions post-onset of labor.

• Indications: To shorten labor.

• Contraindications: Similar to those for vaginal delivery.

• Nursing Actions: Administer pitocin, monitor fetal strip, provide pain control.

Complementary Therapies

• Options: Acupuncture, bowel stimulation, herbal preparations, sexual intercourse.

Operative Vaginal Delivery

Vacuum-Assisted Delivery

• Indications: Potential fetal compromise, prolonged second stage.

• Risks for Women: Lacerations, hemorrhage, bladder trauma.

• Risks for Newborn: Cephalohematoma, intracranial hemorrhage.

• Nursing Actions: Educate client, prepare for complications, monitor closely.

Birth Injuries

• Types of Injuries: Soft tissue, nerve, and head injuries related to uterine dysfunction.

Trial of Labor after Cesarean (TOLAC) and Vaginal Birth after Cesarean (VBAC)

• Benefits: Shorter hospital stays, fewer complications.

• Contraindications: Prior classical incision, uterus abnormalities.

• Risks: Uterine rupture, failed TOLAC.

• Nursing Actions: Explain risks, avoid misoprostol for cervical ripening.

Shoulder Dystocia

• Definition: Birth complication with impaction of fetal shoulder.

• Risk Factors: Macrosomia, history of shoulder dystocia.

• Assessment Findings: Turtle sign, potential lacerations.

• Medical Management: Utilize McRoberts, Woods corkscrew, promote neonatal resuscitation.

• Nursing Actions: Prepare the mother, assist in maneuvers, avoid fundal pressure.

Complications of Shoulder Dystocia

• Maternal Complications: Hemorrhage, lacerations.

• Neonatal Complications: Cardiorespiratory depression, Erb's palsy, fractures.

Umbilical Cord Prolapse

• Definition: Cord lies below the presenting part, potentially causing oxygen deprivation.

• Risk Factors: Malpresentation, polyhydramnios.

• Assessment Findings: Sudden fetal bradycardia, cord felt during SVE.

• Medical Management: Immediate delivery (C/S or vaginal).

• Nursing Actions: Lift fetus off the cord, provide oxygen, IV bolus.

Ruptured Vasa Previa

• Definition: Rupture of fetal blood vessels unsupported by placental tissue.

• Risks: Low-lying placenta, multiple gestations.

• Assessment Findings: Blood or fetal death during ROM.

• Medical Management: Schedule C/S if diagnosed prior.

• Nursing Actions: Prepare for delivery, monitor for bleeding.

Uterine Rupture

• Definition: Tear in uterine muscle, can be partial or complete.

• Risk Factors: Prior C/S, uterine infection.

• Assessment Findings: Hypotension, severe pain, vaginal bleeding.

• Medical Management: Emergency C/S, transfusion.

• Nursing Actions: Prepare for emergency interventions, provide support to the patient.

References

• Durham, R., Chapman, L., & Miller, C. (2022). Davis Advantage for Maternal-Newborn Nursing: Critical Components of Nursing Care (4th Ed.). F. A. Davis Company.

• RN Maternal Newborn Nursing (12th Ed.). (2023). Assessment Technologies Institute.