Study Notes on Deviations from Normal Labor and Delivery

Deviations from Normal Labor and Delivery

Class Objectives

  • Recognize cues associated with complications of labor:

    • Abnormal labor patterns, dystocia, fetal malpresentation, preterm labor, rupture of membranes.

  • Analyze cues using the 5 P’s of labor framework:

    • Powers, passenger, passageway, position, psyche to determine potential causes of ineffective labor progression.

  • Prioritize nursing interventions for patients experiencing complications:

    • Monitoring maternal-fetal status, preventing infection, supporting safe progression of labor, preparing for operative birth.

  • Evaluate clinical decisions related to induction and augmentation of labor:

    • Cervical readiness (Bishop score), pharmacologic interventions, and maternal-fetal responses to treatment.

Normal Labor Review

  • 1st Stage:

    • Latent Phase: 0-6 cm dilation

    • Active Phase: 6 cm – fully dilated

    • Transitioning Phase: Between 8-10 cm dilation

  • 2nd Stage:

    • Pushing Phase: Can take up to 3 hours; delivery of the baby

  • 3rd Stage:

    • Delivery of Placenta: Generally takes 15-30 minutes

Dystocia

  • Definition: The abnormal progression of labor

Dystocia Causes

  • Complications:

    • Hemorrhage

    • Infections

    • Perineal lacerations

    • Anal sphincter injury

  • Factors:

    • Expulsive forces

    • Fetal presentation and positioning

    • Maternal pelvic structure (Cephalopelvic Disproportion, CPD)

    • Maternal fatigue and stress

The 5 P's

  • How do they affect labor dystocia?

  • Powers:

    • Hypertonic/hypotonic uterine dysfunction

    • Arrest of descent

    • Dysfunctional labor patterns

    • Precipitous labor

  • Passageway:

    • Obstruction in maternal birth canal

    • Pelvic contraction

  • Passenger:

    • Occiput Posterior Position (OP)

    • Breech presentation

    • Macrosomia and CPD

    • Multifetal pregnancy

  • Position:

    • Fetal and maternal positioning

  • Psyche:

    • Anxiety and distress

Problems: Expulsive Forces

  • Hypertonic Uterine Dysfunction:

    • Strong contractions but loss of downward pressure on the cervix. Usually stalls < 4 cm, may be uncoordinated contractions.

    • Nursing Management:

    • Evaluate FHR

    • Evaluate for any signs/symptoms of abruption

    • Support mom with rest, IV hydration

    • Amniotomy to augment

    • Reassurances and assessment for infection

    • Follow orders for medications (rest or augment)

  • Hypotonic Uterine Dysfunction:

    • Contractions decrease in strength and consistency, labor stalls.

    • Nursing Management:

    • Evaluate FHR

    • Evaluate for true vs false labor

    • Check for infection if ruptured

    • Support client and family

    • Administer oxytocin to induce/augment if indicated/ordered.

  • Precipitous Labor:

    • Abrupt onset of active labor quickly passing through the stages.

    • Nursing Management:

    • Monitor FHR

    • Support client and family

    • Plan and support vaginal delivery if pelvis is adequate

Problems: Fetal Presentation, Position, or Development

  • Persistent Occiput Posterior Position (OP):

    • Engagement of fetal head in an unfavorable position; labor is longer, more uncomfortable.

    • Nursing Management:

    • Assess FHR

    • Evaluate for fetopelvic disproportion

    • Support position changes in client (rocking, kneeling, squatting, sitting on pregnancy ball)

    • Apply counterpressure to back

    • Administer pain management as indicated; support for epidural if wanted.

  • Face or Brow Presentation:

    • Brow/face is engaged, flexion did not occur correctly; longer labor, uncomfortable.

    • Nursing Management:

    • Evaluate FHR

    • Support position changes

    • Prepare and support cesarean delivery if needed

  • Breech Presentation (Frank, Complete, or Footling) and Transverse Presentation:

    • Confirm by ultrasound that head is not presenting part.

    • Assess FHR

    • Version may be discussed; plan for cesarean delivery.

  • Shoulder Dystocia:

    • Delivery of fetal head with inability to advance shoulders through birthing canal; EMERGENCY - risk of fetal hypoxia.

    • Nursing Management:

    • McRoberts maneuver

    • Suprapubic pressure

    • Newborn resuscitation team at bedside

    • Anticipate emergent surgical delivery if unsuccessful.

  • Multiple Pregnancy:

    • Monitor both FHRs, evaluate labor; can deliver vaginally if able.

    • Neonatal team at bedside for vaginal and cesarean deliveries.

  • Macrosomia or other Fetal Abnormalities:

    • If allowed trial of labor, assess for fetal descent into pelvis; anticipate vacuum-assisted delivery if vaginal.

    • Plan for c-section if indicated; monitor FHR and support client.

Problems with the Maternal Pelvis or Birth Canal

  • Small pelvis can cause obstruction in the canal; patience with labor is essential.

  • Nursing Management:

    • Allow natural forces to push down

    • Evaluate bowel and bladder status to reduce any pressure or obstructions

    • Evaluate FHR

    • Support client; if failed trial of labor, support during cesarean delivery.

  • Problems with Maternal Fatigue/Stress:

    • Labor can release stress-related hormones, potentially leading to relaxation of uterine muscles.

    • Nursing Management:

    • R/o other causes of slow labors

    • Provide a comfortable and private environment

    • Monitor fetal status and client well-being

    • Frequent updates and include client in conversations and planning.

Dystocia: Nurse’s Role

  • Conduct nursing assessments

  • Promote the progress of labor

  • Provide physical and emotional comfort

  • Advocate for patient rights and care

Complications of Labor

  • Increased perinatal morbidity and mortality risks when complications arise.

  • Some complications are anticipated, especially when mothers are identified as high risk.

  • Vigilance is necessary even in uncomplicated pregnancies with low-risk clients, as complications can arise unexpectedly.

Preterm Labor

Causes and Care Management Interventions

  • Preterm Labor and Birth Classifications:

    • Late preterm: 34 weeks to 36 weeks and 6 days

    • Moderate preterm: 32 weeks to 33 weeks and 6 days

    • Very preterm: Less than 32 weeks

    • Extremely preterm: Less than 28 weeks

  • Definitions:

    • Preterm Labor: Contractions resulting in some effacement and dilation between 20-37 weeks of gestation.

    • Preterm Birth: Defined as the birth of an infant before 37 completed weeks of gestation.

Causes of Preterm Labor & Deliveries

  • Maternal and/or Pregnancy Related:

    • Pre-existing DM or GDM

    • Intrauterine growth restriction (IUGR)

    • Chronic HTN or preeclampsia

    • Abnormal NST or BPP

    • Placental disorders

    • Poly/oligohydramnios

    • Obesity, smoking, advanced maternal age

    • Multiple gestation

    • Cholestasis of pregnancy

    • Blood group alloimmunization

    • Autoimmune and connective tissue disorders

    • Birth defects

    • Clotting disorders

Identifying Clients at Risk for Preterm Labor

  • Identify the risk: is it maternal or fetal?

  • Evaluate for s/s for PTL:

    • Contractions that do not stop with rest/hydration

    • Signs/symptoms of PPROM

    • Check for cervical length; if <2.5cm

    • Assess for fetal fibronectin: protein produced around time of labor. If negative, unlikely that labor will start in the next couple of weeks; if positive, requires additional monitoring/testing.

Care of the Client at Risk for Preterm Labor/Birth

  • Assessments are critical: Determine risk factors.

  • Interventions:

    • Prevention and early recognition

    • Educate on lifestyle modifications, activity restrictions, including pelvic rest

    • Administration of medications:

    • Antenatal glucocorticoids for fetal lung maturity (dexamethasone, betamethasone)

    • Magnesium sulfate before 32 weeks (neuroprotection)

Medication Classifications

  • Tocolytics:

  • Uterotonics:

  • Prostaglandins:

  • Corticosteroids:

  • Medications to stop contractions:

    • Magnesium sulfate: CNS depressant that relaxes smooth muscle inhibiting uterine activity

    • Beta-Adrenergic Agonist (Beta-Mimetic): Terbutaline, relaxes smooth muscle inhibiting uterine activity.

    • Prostaglandin Synthetase Inhibitors (NSAIDs): Indomethacin, inhibits prostaglandins, thus inhibiting uterine activity

    • Calcium Channel Blockers: Nifedipine blocks calcium entry into smooth muscle cells, inhibiting uterine activity

PROM: Premature Rupture of Membranes

  • Definition: Rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of labor at any gestational age (37 weeks +).

  • PPROM: Preterm Premature Rupture of Membranes – Membrane rupture before 37 0/7 weeks of gestation

  • Infection is a major risk factor: Responsible for one third of all preterm births.

  • Etiologies can include:

    • Pathologic weakening of amniotic membranes, inflammation, stress from uterine contractions, other factors

Care of Client with PROM or PPROM

  • Assessments:

    • Risk factors and signs/symptoms of labor

    • Electronic fetal heart rate monitoring

    • Amniotic fluid characteristics (COAT) testing: Nitrazine test, Fern test, ultrasound for fluid check

  • Nursing Management:

    • Infection prevention: no unsterile cervical exams until client is in active labor or medically necessary

    • Identification of uterine contractions, education and support

    • Possible discharge home (PPROM) if no labor within 48 hours

Prolapsed Umbilical Cord

  • Obstetric Emergency:

    • Contributing factors include: long cord (longer than 100 cm), malpresentation (breech), transverse lie, unengaged presenting part, polyhydramnios, and multiple gestation

  • Nursing Assessment and Management:

    • Assess for risk, prompt recognition of the situation.

    • Do not leave the patient, stay calm.

    • Continuous assessment of client and fetus

    • Have woman move into knee-chest position or modify to extreme Trendelenburg or use a rolled towel under the mother’s hip.

    • Glove hand and push presenting part up to relieve pressure on cord.

    • Do not attempt to replace cord into vagina or cervix; prepare for emergent cesarean.

    • Explain to support person the situation and plan.

Chorioamnionitis

  • Definition: Bacterial infection of the amniotic fluid, membranes, placenta, and uterus that occurs when pathogens ascend from the vagina into the amniotic cavity.

  • Associated with:

    • Preterm labor, neonatal sepsis, and maternal infection.

  • Clinical findings include:

    • Maternal fever, fetal tachycardia, uterine tenderness, foul-smelling amniotic fluid

  • Nursing Management:

    • Continuous monitoring of maternal and fetal status

    • Administration of prescribed broad-spectrum antibiotics

    • Possible delivery if indicated

    • If preterm, administer antenatal corticosteroids

Additional Complications

  • Post-term Pregnancy: Pregnancy extends beyond the end of 42 weeks gestation.

    • Maternal Risks:

    • Labor dystocia, cesarean birth, birth trauma, postpartum infection, hemorrhage

    • Fetal Risks:

    • Macrosomia, shoulder dystocia, brachial plexus injuries, low APGAR scores, post-maturity syndrome.

    • Kick counts for evaluation and NST

Breech Presentation

  • Definition: Fetus’ buttocks or feet are closest to the cervix; external cephalic version can be attempted around 36-37 weeks.

  • Nursing Assessments in ECV:

    • Continuous fetal monitoring before, during, and after

    • Baseline, variability, presence of accelerations and decelerations, especially bradycardia

    • Maternal vital signs, uterine activity, comfort, signs of labor, bleeding, or membrane rupture

Induction or Augmentation of Labor

  • Induction: Initiate uterine contractions by any pharmacological, mechanical, or medical method.

  • Augmentation: Enhancement of spontaneous uterine contractions that are inadequate to produce cervical change or fetal descent.

WHO Recommendations for Induction of Labor

  • Induction should be performed only when there is a clear medical indication, weighing expected benefits against potential harms.

  • Consider individual conditions, wishes, and preferences of each woman, emphasizing cervical status and specific induction method.

Indications for Induction/Augmentation of Labor

  • Maternal Conditions:

    • Post-term pregnancy, PIH, diabetes mellitus, maternal or fetal medical conditions, placental insufficiency, prolonged pre-labor ROM

  • Fetal Conditions:

    • Suspected fetal compromise, intrauterine death (IUFD), IUGR, post-dates, oligohydramnios/polyhydramnios, pregnancy >41 weeks

Contraindications to Induction of Labor

  • Active vulvovaginal herpetic lesions, acute fetal distress, shoulder presentation, floating fetal part, placenta previa, previous uterine incision that prohibits trial of labor, multiple gestation, suspected CPD, inability to monitor fetal heart rate adequately throughout labor.

Elective Induction of Labor

  • Inducing labor without a medical indication, often for convenience.

  • Risks associated: Increased rates of cesarean birth, neonatal morbidity, increased costs; should not be initiated until at least 39 completed weeks of gestation.

Induction of Labor Components

  • Stages:

    • Cervical ripening

    • Uterine contractions

    • Cervical dilation and effacement

    • Delivery

Assessments Before Induction of Labor

  • Maternal:

    • Confirm indication and exclude contraindication for IOL

    • Bishop score (>6 is favorable)

  • Fetal:

    • Ensure gestational age, estimated fetal weight, ensure fetal lung maturity, presentation, and lie, confirm fetal well-being

Bishop Scoring System

  • Assess cervical favorability for vaginal birth:

    • Score based on:

    • Dilation (cm), position of cervix, effacement (%), station, cervical consistency

  • Example Given:

    • A patient’s cervical exam shows:

    • 3 cm dilation

    • 70% effaced

    • Station –1

    • Soft cervix

    • Mid-position cervix

Cervical Ripening

  • Non-pharmacological methods:

    • Stripping of membranes

  • Pharmacologic Methods:

    • Prostaglandins (Misoprostol and Dinoprostone): Softens cervix and stimulates contractions

    • Mechanical dilators

    • Osmotic dilators (laminaria)

    • Balloon catheter

    • Mifepristone (Mifeprex): Causes breakdown of uterine lining and detachment of pregnancy

Medication Information

  • Dinoprostone (Cervidil, Prepidil):

    • Cervical ripening; may stimulate contractions; used for labor induction.

    • Route: vaginal insert or gel; continuous fetal monitoring required.

  • Misoprostol (Cytotec):

    • Used for labor induction, cervical ripening, postpartum hemorrhage; can have side effects like uterine tachysystole.

  • Oxytocin (Pitocin):

    • Stimulates uterine contractions; used for augmentation or treatment of hemorrhage.

    • Administered IV; titrated with close fetal monitoring required.

    • Risks include uterine tachysystole, fetal distress.

  • Mifepristone:

    • Antiprogestin used for medical abortion; monitor for bleeding and cramping post-administration.

Amniotomy: Artificial Rupture of Membranes

  • Procedure:

    • Assess fetal heart rate before and after.

    • Position client with hips elevated; explain procedure to client.

    • Evaluate amniotic fluid characteristics post rupture, monitor for infection signs.

Augmentation

  • Definition: Using medical procedures to cause stronger and more frequent contractions aimed at opening the cervix.

Methods to Augment Labor

  • Augmentation Methods:

    • Administration of oxytocin or artificial rupture of membranes

  • Nursing Care:

    • Ensure bladder is empty, assist with position changes, ensure hydration and relaxation.

Emergency Treatment for Uterine Tachysystole during Oxytocin Infusion

  • Signs of Tachysystole:

    • More than five contractions in 10 min or lasting over 2 min

    • Insufficient return of uterine resting tone

  • Interventions (normal FHR tracing):

    • Reposition the client, administer IV fluid bolus, decrease or discontinue oxytocin if not improved in 10-15 min.

  • Interventions (abnormal FHR tracing):

    • Discontinue oxytocin immediately, reposition client, administer IV fluids, consider oxygen supplementation, notify obstetric healthcare provider of interventions taken.

Operative Vaginal Birth

  • Application:

    • Used in cases of prolonged 2nd stage of labor, non-reassuring FHR pattern, limited sensation or inability to push effectively.

Risks Associated with Assisted Vaginal Delivery

  • Maternal Risks:

    • Perineal trauma, hematoma post-delivery

  • Newborn Risks:

    • Trauma, brachial plexus injury, cephalohematoma

Vacuum Extraction Considerations

  • Indication: Must be >=34 weeks' gestation, ROM, dilated cervix, patient consent, and engaged head.

Forceps Assisted Delivery Considerations

  • Types: Fenestrated blades (Simpson), solid blades (Elliot, Piper, Kielland, Bailey-Williamson, Tucker-McLean).

Perineal Laceration

  • Defined as a tear of perineal tissue categorized in terms of degree:

    • First-Degree: Involves the vaginal mucosa

    • Second-Degree: Involves vaginal mucosa and perineal muscles

    • Third-Degree: Involves vaginal, perineal muscles, and anal sphincter

    • Fourth-Degree: Extends through rectal mucosa

  • Nursing Consideration: Repair is essential; if undiagnosed or unrepaired can lead to infections and hemorrhage.

Shoulder Dystocia

  • Obstetric Emergency: Labeled when the anterior shoulder is compressed against the symphysis pubis.

  • Signs: Head delivered but then retracts back onto perineum (turtle sign).

  • Action: Call for help immediately.

McRoberts Maneuver

  • Procedure: Perform during shoulder dystocia to relieve impaction; risks include lower limb neuropathy.

Meconium-Stained Amniotic Fluid (MEC)

  • Definition: Represents the first stool of the fetus/newborn, can be green, yellow, or brown stained fluid passed into the amniotic fluid; often seen with fetal maturity or stress.

  • Clinical Significance: Main concern is if the newborn inhales the meconium-stained fluid, which could lead to respiratory distress and other severe complications.

Nursing Responsibilities during MEC Events

  • Monitor fetal heart rate patterns, assess color, consistency, and amount of amniotic fluid, notify provider, and ensure neonatal resuscitation team is present at delivery.

Uterine Rupture

  • Initial Condition: Fetus in utero with placenta attached; prior scar tissue from previous cesarean section can lead to this.

  • Signs and Nursing Priority: Sudden fetal distress and severe pain, prepare for emergent cesarean delivery.

Cesarean Delivery

Pre-Operative Teaching

  • Education: Explain what and why the cesarean section is necessary, provide breastfeeding management information, and educate on pain management.

  • Prepare for the post-operative period by supporting partners.

Post-Operative Care

  • Assessments: Examine the dressing, comfort levels, perineal pad every 15 minutes in the first hour, fundal assessment for firmness, administer IV oxytocin, assist with respiratory measures (coughing and deep breathing), and support bonding with the newborn.

Amniotic Fluid Embolism

  • Definition: Acute condition where amniotic fluid containing particles enters the maternal bloodstream, causing a severe allergic-like response.

  • Outcomes: Maternal mortality associated with amniotic fluid embolism can range from 60-80%. Neonatal outcomes often remain poor.

Nursing Assessment and Management for Amniotic Fluid Embolism

  • Signs to monitor: Poor oxygenation, hypotension, signs of coagulopathy such as DIC, and prepare for critical care monitoring.

  • Supportive measures to maintain oxygenation and hemodynamic function are essential.