Complications of Labor and Birth Flashcards

Learning Objectives for Labor and Birth Complications

• Examine the Anatomy, Physiology, and Pathophysiology: Analyze the structural and functional changes associated with complications during labor and birth.
• Explore Epidemiological and Etiological Risk Factors: Investigate the statistics and causes that contribute to labor complications.
• Describe Overall Health Impact: Evaluate how maternal and fetal complications affect the long-term and immediate health of the clients.
• Differentiate Clinical Presentation and Treatment: Distinguish between various complications through their symptoms and prescribed medical interventions.
• Explore the Role of the Nurse: Define the responsibilities of nursing staff in managing complex labor scenarios.
• Apply the Nursing Process and Clinical Judgment: Use assessment, analysis, planning, implementation, and evaluation to provide care for clients experiencing complications.

Anatomy and Physiology Considerations

• Fetal Anatomy and Physiology:     * Viability: Refers to the point in fetal development when the fetus is capable of surviving outside the uterus.     * Periviable: Refers to the period of gestation immediately preceding viability, where survival is possible but highly uncertain and often associated with high morbidity.
• Maternal Anatomy and Physiology:     * Changes of Pregnancy: Physiological adaptations across body systems that may influence labor progression.     * Pelvic Shape: The structural configuration of the bony pelvis, which determines the ease of fetal passage.     * Cervical and Perineal Resistance: The resistance provided by the soft tissues of the cervix and perineum during the second stage of labor.     * Amniotic Membranes: The integrity and timing of the rupture of the sac surrounding the fetus.

Grief, Loss, and Psychosocial Support

• Grief Related to Perceived Birth Plan: Clients may experience grief when labor does not proceed as planned, leading to a sense of loss of the intended "experience."
• Complications and Fetal Loss: Clinical complications can lead to the death of the fetus, necessitating intensive emotional support.
• Disenfranchised Grief: A type of grief that is not openly acknowledged, socially validated, or publicly mourned, often felt by parents experiencing early fetal loss or elective procedures.
• Nursing Interventions for Grief:     * Individualized Support: Tailoring care to the specific cultural, spiritual, and emotional needs of the family.     * Facilitate Grieving: Providing time and space for parents to hold the infant or collect mementos (photographs, footprints).     * Care of Support Person(s): Ensuring that partners and family members also receive emotional check-ins and resources.

Preterm Labor and Birth

• Pathophysiology: Defined as regular uterine contractions that result in cervical change occurring prior to the completion of the $37^{\text{th}}$\,week of gestation.     * Early Preterm: Up to $34$\,weeks.     * Late Preterm: Between $34$\,weeks and $37$\,weeks.     * Note: Preterm labor does not always result in a preterm birth; interventions may successfully arrest labor.
• Etiology and Risk Factors:     * Maternal history of previous preterm birth.     * Multiples (twins, triplets, etc.).     * Low body mass index (BMI).     * Maternal age over $35$\,years or early adolescent pregnancy.     * Use of Assistive Reproductive Technology (ART).     * Short interval between pregnancies (less than $18$\,months).     * Substance abuse and exposure to partner violence.
• Co-morbidities:     * Maternal depression.     * Gestational Diabetes Mellitus (DM).     * Hypertensive disorders.     * Genitourinary (GU) tract infections and Sexually Transmitted Infections (STIs).
• Epidemiology: Affects approximately $10\%$ of pregnancies annually worldwide. In the United States, rates decreased slightly in $2022$.
• Clinical Presentation: Often involves subtle changes such as backache, pelvic pressure, or increased vaginal discharge.
• Diagnostics:     * Non-stress test (NST).     * Biophysical Profile (BPP) and Ultrasound.     * Fetal Fibronectin (fFN): A protein "glue" that attaches the fetal sac to the uterine lining; its presence between $22$ and $34$\,weeks can indicate a risk of preterm labor.
• Treatments and Therapies:     * Identify and treat underlying causes (e.g., dehydration, infection).     * Tocolysis (Medications to stop labor):         * Terbutaline administered subcutaneously.         * Oral Nifedipine.         * Magnesium Sulfate (IV): Primarily used for neuroprotection of the fetus and to allow time for corticosteroid administration.     * Corticosteroids: Administered to promote fetal lung maturity in the event of preterm birth.     * Cerclage: A surgical procedure to reinforce a weak cervix, typically performed at $12$ to $16$\,weeks, or up to $24$\,weeks in emergencies.
• Nursing Interventions:     * Sample collection for diagnostic testing.     * Facilitating comfort and ensuring adequate perfusion.     * Monitoring vital signs and administering tocolytics.     * Education on prenatal care, risk factors, and when to notify the provider.

Preterm/Prelabor Rupture of Membranes (PPROM)

• Definition and Risks: Rupture of membranes before the onset of labor in a patient less than $37$\,weeks gestation. It increases the risk for maternal/fetal infection, impaired fetal lung development, cesarean birth, hemorrhage, and infant respiratory distress.
• Epidemiology: Occurs in $2\%$ to $3\%$ of all pregnancies and accounts for $40\%$ of spontaneous preterm births.
• Etiology and Risk Factors:     * Low socioeconomic status and low pre-pregnancy BMI.     * Tobacco use.     * History of PPROM, infection, or short cervical length.     * Vaginal bleeding.     * Co-morbidities: Gestational DM, hypertensive disorders, cardiac disease, polycystic kidney disease, and sickle cell disease.
• Diagnostics:     * Visual assessment: Color, odor, amount, and time of rupture.     * Fern Test: Examining a slide under a microscope for a fern-like pattern of dried salts.     * Nitrazine Test: pH paper that turns blue in the presence of alkaline amniotic fluid.     * Amniotic protein tests and Ultrasound to assess fluid volume.
• Treatments and Therapies:     * Near Term: Expectant management or induction of labor.     * Preterm: Tocolytics, antibiotics, activity limitations, corticosteroids, or magnesium sulfate depending on gestation.
• Complications: Maternal or fetal sepsis, cesarean birth, and fetal respiratory problems.
• Nursing Interventions:     * Provide frequent pad changes and maintain hydration/nutrition.     * Assess fetal heart tones (FHTs) and contractions.     * Avoid Vaginal Exams: To prevent the introduction of bacteria and reduce the risk of infection.

Chorioamnionitis

• Definition: An ascending bacterial infection resulting in inflammation of the amniotic fluid, placenta, uterus, fetus, and amniotic membranes. Also known as intraamniotic infection.
• Etiology and Epidemiology:     * Can be bacterial, viral, or fungal.     * Most common in preterm labor or prolonged rupture of membranes (ROM).     * Affects $3\%$ to $5\%$ of term births in the U.S.     * Affects up to $70\%$ in PPROM cases.     * Evidence of infection is found in $94\%$ of periviable births.
• Risk Factors: Assistive reproductive technology, smoking, alcohol use, induction with a cervical balloon, meconium-stained fluid, and multiple vaginal exams during labor.
• Manifestations:     * Fever: Greater than $38^{\circ}\text{C}$ ($100.4^{\circ}\text{F}$) measured on two occasions $30$\,minutes apart.     * Uterine tenderness and purulent (foul-smelling) amniotic fluid.     * Maternal and fetal tachycardia.     * Elevated White Blood Cell (WBC) count (Leukocytosis).
• Diagnostics: Amniotic fluid culture, elevated C-reactive protein, and placental pathology.
• Treatment: IV antibiotics and transfer to a higher acuity unit if necessary.
• Considerations: Dysfunctional labor, neonatal complications, stress/anxiety, and screening for Group B Streptococcus (GBS).

Dysfunctional Labor: Augmentation and Induction

• Best Practice: Allow labor to begin spontaneously whenever possible.
• Definitions:     * Augmentation: Medications or interventions to help progress labor that has already begun spontaneously but is ineffective.     * Induction: The use of medications or mechanical techniques to initiate labor.
• Indications: Dysfunctional labor (ineffective contractions), maternal/fetal anatomical disproportion, or comorbidities requiring delivery for fetal safety.
• Friedman Curve: A graph used to track the progress of cervical dilation and fetal station against time to identify dysfunctional labor patterns.
• Interventions:     * Pitocin (Oxytocin): IV medication to stimulate contractions.     * Amniotomy: Artificial rupture of membranes (AROM).     * Non-invasive: Hydration, nutrition, ambulation, position changes, emptying the bladder, and relaxation techniques.
• Risks: Postpartum uterine atony and hemorrhage, altered bonding, and breastfeeding difficulties.

Breech Presentation

• Types:     * Frank: Hips flexed, knees extended (feet near head).     * Complete: Hips and knees flexed (sitting cross-legged).     * Footling/Incomplete: One or both feet presenting first.
• Causes: Uterine malformations, congenital anomalies, placenta previa, abnormal amniotic fluid volume, multiple gestation, or low birth weight.
• Management:     * External Cephalic Version (ECV): Manual attempt to turn the fetus; risks include placental abruption, uterine rupture, or cord prolapse.     * Continuous monitoring of FHTs and contractions.     * Rh status check; administer Rho(D) immune globulin if indicated.     * Patient must be NPO (nothing by mouth) in case of emergency surgery.

Fetal Heart Rate (FHR) Patterns

• Reassuring Patterns:     * Baseline range: $110$ to $160$\,beats/min.     * Moderate variability.     * Occasional accelerations.
• Non-Reassuring Patterns: Caused by fetal hypoxia or neurological dysfunction.     * Tachycardia/Bradycardia.     * Decreased or Absent Variability.     * Decelerations.
• Category Classification:     * Category I: Normal. Baseline $110-160$\,bpm, moderate variability, no late/variable decels.     * Category II: Indeterminate. Requires continued monitoring and re-evaluation.     * Category III: Abnormal. Absent variability with recurrent late decels, recurrent variable decels, bradycardia, or a sinusoidal pattern.
• Clinical Findings table:     * Tachycardia: Modifiable factor is maternal fever; dire concern is chronic hypoxia.     * Bradycardia: Modifiable factor is cord compression; dire concern is hypoxia, uterine rupture, or abruption.     * Minimal Variability: Modifiable factor is fetal sleep cycle; dire concern is neurological dysfunction.     * Early Decelerations: Caused by fetal head compression; concern for transition to late decels.     * Variable Decelerations: Caused by cord compression; concern for recurrent/prolonged patterns.     * Late Decelerations: Caused by encephalopathy, acidosis, or hypoxia.
• Intrauterine Resuscitation: Oxygen administration, repositioning, and preparing for urgent birth.

Meconium Staining

• Pathophysiology: The passage of fetal stool in utero, often indicating fetal hypoxia.
• Meconium Aspiration Syndrome (MAS): Risk of the infant inhaling meconium, leading to severe respiratory distress.
• Risk Factors: Post-term pregnancy, breech presentation, chorioamnionitis, preeclampsia, and maternal comorbidities.
• Grades of Staining:     * Grade 1: Lightly stained or thin fluid.     * Grade 2: Green or yellow stained; may contain flecks.     * Grade 3: Dense/thick fluid with "pea soup" consistency.
• Treatment: Amnioinfusion (infusing fluid into the uterus to dilute meconium) unless contraindicated by placenta previa, HIV, or herpes.

Operative Vaginal Birth

• Definition: Intervention using a vacuum extractor or forceps to aid fetal descent.
• Prevalence: Approximately $3\%$ of U.S. births.
• Maternal Complications: Tissue trauma, increased pain, hemorrhage, and postpartum incontinence.
• Fetal Complications:     * Vacuum: Cephalohematoma, intracranial hemorrhage, scalp lacerations, and brachial plexus injury (Erb-Duchenne Palsy).     * Forceps: Facial lacerations, facial nerve palsy, ocular trauma, and skull fractures.
• Criteria: Cervix must be fully dilated, membranes ruptured, and fetal weight/position assessed.

Obstetric Emergencies

Prolapsed Umbilical Cord

• Description: The cord slips below the presenting part, leading to compression and fetal hypoxia. It may be visible or felt during an exam.
• Signs: FHR showing prolonged decelerations, bradycardia, or recurrent variable decelerations.
• Nursing Actions (FROM AI):     * F: Fetal presenting part elevated with a sterile gloved hand.     * R: Rapid response team notified.     * R: Reposition client (e.g., knee-chest or Trendelenburg).     * O: Oxytocin discontinued.     * M: Monitor fetal heart rate.     * A: Apply oxygen if prescribed.     * I: Insert IV and indwelling urinary catheter; instill sterile fluid into the bladder to help lift the fetus off the cord.

Placental Abruption (Abruptio Placentae)

• Description: Premature separation of the placenta from the uterine wall.
• Classification:     * Class 0: Asymptomatic; discovered after birth via clot on placenta.     * Class 1 (Mild): Slight tenderness, reassuring FHR, small amount of bleeding.     * Class 2 (Moderate): Significant tenderness, vital signs outside expected range, non-reassuring FHR.     * Class 3 (Severe): Tetanic ("board-like") abdomen, maternal hypovolemic shock, fetal death.
• Diagnostics: Kleihauer-Betke test (detects fetal blood in maternal circulation), CBC, and clotting studies.

Uterine Rupture

• Description: The three layers of the uterus tear apart, frequently associated with previous cesarean scars.
• Signs: Sudden loss of uterine contractions (atony), referred shoulder/chest pain, loss of fetal station, and hypotension.
• Emergency Interventions: Reposition to lateral, stop oxytocin, apply $10\,\text{L/min}$ oxygen via non-rebreather mask, initiate two large-bore IVs ($20$\,gauge minimum), and prepare for emergency hysterectomy or repair.

Shoulder Dystocia

• Sign: The "Turtle Sign" (fetal head retracts against the perineum).
• Management (CAMPEER):     * C: Call for help.     * A: Apply suprapubic pressure (avoiding the fundus).     * M: Movement of the fetal arm by the provider.     * P: Position the client onto hands and knees.     * E: Prepare for an episiotomy.     * E: Elevate legs to knee-chest position (McRoberts Maneuver).     * R: Rotation of the fetus manually.

Questions & Discussion

• Fetal Loss: What types of support can the nurse provide to a client and their support persons when dealing with a fetal loss?
• Complications: What are the potential complications associated with preterm or prelabor rupture of membranes? Discuss what nursing interventions should be prioritized for care of this patient.
• Emotional Support: Discuss the importance of providing emotional support for team members that are providing care for a patient experiencing fetal demise.
• Interventions: Discuss the various complications of labor and their associated nursing interventions.