Nursing Care of Women with Complications During Labor and Birth

Nursing Care of Women with Complications During Labor and Birth

Labor Induction and Augmentation

  • Induction:

    • Definition: Initiation of labor before natural onset begins.

    • Bishop Score: Score of 6 or more predicts a favorable prognosis for induction.

    • Key factor: Cervical readiness.

  • Augmentation:

    • Definition: Stimulation of contractions after natural onset of labor.

Indications for Labor Induction

Maternal Indications

  • Gestational Hypertension: Elevated blood pressure during pregnancy.

  • Ruptured Membranes: Without spontaneous labor onset.

  • Infection: Presence within the uterus.

  • Medical Complications: Worsening conditions in the mother during pregnancy.

Fetal Indications

  • Fetal Problems: Issues like prolonged pregnancy or blood type incompatibility.

  • Placental Insufficiency: Placenta cannot deliver adequate nutrients and oxygen.

  • Fetal Death: Induction may be warranted if the fetus is no longer viable.

Contraindications to Labor Induction

  • Placenta Previa: Placenta covers the cervix, leading to complications.

  • Umbilical Cord Prolapse: Cord slips ahead of the fetus during labor.

  • Abnormal Fetal Presentation: Improper positioning of the fetus.

  • Active Herpes Infection: Presence in the birth canal.

  • Maternal Pelvic Abnormalities: Issues with pelvic size/structure.

  • Previous Classic Cesarean Incision: Previous surgical incision increases risks.

Prolapsed Umbilical Cord Management

  • Intervention: A gloved hand may be inserted into the vagina to push the fetus off the cord.

  • Positions:

    • Knee-Chest Position:

    • Thighs at right angles to the bed; chest flat against the bed.

    • Elevation of hips with pillows, combined with Trendelenburg position (head down).

Methods to Stimulate Contraction

Pharmacological Methods

  • Cervical Ripening: Prostaglandin gels or vaginal inserts to soften the cervix.

  • Oxytocin/Pitocin: Induction or augmentation of labor to stimulate contractions.

  • Commonality: Most prevalent method used in clinical settings.

Nonpharmacological Methods

  • Walking: Encourages natural contraction processes.

  • Nipple Stimulation: Can trigger release of oxytocin for contractions.

Complications of Oxytocin Induction

  • Common Complications:

    • Overstimulation of contractions leading to potential fetal distress.

    • Uterine rupture risks.

    • Amniotomy: Artificial rupture of membranes can cause complications like cord prolapse, infections, and uterine overdistension leading to abruptio placentae.

Version Procedure

  • External Version: A method to change fetal presentation, usually guided by ultrasound and monitored for fetal heart tones post-procedure.

Episiotomy and Lacerations

Episiotomy

  • Definition: A controlled surgical enlargement of the vaginal opening during birth.

  • Indications: Discussion on alternatives like perineal massage and stretching exercises.

Lacerations

  • Definition: Uncontrolled tears in tissues resulting in jagged wounds.

  • Types of Perineal Lacerations:

    • 1st Degree: Involves superficial vaginal mucosa or perineal skin.

    • 2nd Degree: Involves vaginal mucosa, perineal skin, and deeper tissues.

    • 3rd Degree: Similar to 2nd degree but also includes the anal sphincter.

    • 4th Degree: Extends through the anal sphincter into the rectal mucosa.

Extraction Methods

Forceps Extraction

  • Purpose: Provides traction and rotation to the fetal head when maternal pushing is inadequate. Can also assist with extraction during cesarean sections.

Vacuum Extraction

  • Purpose: Uses suction on the fetal head to aid the mother's efforts during delivery; primarily utilized with occiput presentation.

Risks of Extraction

  • Potential maternal and fetal tissue trauma.

  • Mothers may experience lacerations or hematomas, infants can have bruising or injuries such as cephalohematomas or intracranial hemorrhages.

Cesarean Birth

  • Definition: Surgical delivery via incision in the abdomen and uterus.

Indications for Cesarean Birth

  • Abnormal Labor: Complications preventing delivery.

  • Maternal Conditions: Gestational Hypertension (GH), Diabetes Mellitus (DM), active maternal herpes, prior uterine surgeries, or fetal compromise.

  • Placenta Conditions: Previa or abruptio placentae.

Risks Associated with Cesarean Birth

  • Mother: Anesthesia complications, respiratory issues, hemorrhage, blood clots, injury, delayed peristalsis, infections.

  • Neonate: Delayed absorption of lung fluid leading to respiratory problems; potential physical injuries during delivery.

Types of Uterine Incisions

  • Vertical Incision: Provides more room for larger fetuses, allowing VBAC possibility.

  • Transverse (Pfannenstiel) Skin Incision: Low transverse is least likely to rupture in future pregnancies.

  • Classic Incision: Rare; greater blood loss, higher risk of rupture.

Nursing Care in the Recovery Room

  • Assessments:

    • Vital signs, fundal firmness and height in relation to the umbilicus, dressing drainage, lochia characteristics (quantity, color, clots), and indwelling catheter output.

Abnormal Labor

Dysfunctional Labor

  • Definition: Labor fails to progress normally.

Dystocia

  • Definition: Difficult labor with identifiable risk factors including:

    • Advanced maternal age.

    • Obesity.

    • Overdistension due to hydramnios or multiple fetuses.

    • Abnormal presentations or cephalopelvic disproportion (CPD).

    • Stimulation-related complications or maternal fatigue.

Hypotonic Labor

  • Definition: Normal labor initiation but lacks progress during the active phase.

  • Causes: usually overdistention resulting in muscle fiber stretch and ineffective contractions.

Ineffective Maternal Pushing

  • Factors:

    • Lack of understanding of techniques, fears of tearing, or absence of contraction urge.

  • Nursing Care: Providing coaching, encouraging pushing during strong urges, alleviating fears, promoting relaxation, repositioning, and hydration.

Problems with Fetal Size

  • Macrosomia: Fetal weight over 4000 g (8.8 lbs); can hinder vaginal birth.

  • Shoulder Dystocia: An emergency requiring prompt interventional maneuvers; assessments for injuries in mother and infant post-delivery.

    • McRoberts Maneuver: Specific technique employed for management.

    • Suprapubic Pressure: Applied to assist in resolving dystocia.

Problems with Fetal Presentation

  • Definitions and Implications: Abnormal presentations can obstruct passage; common presentations include breech and face.

  • Nursing Care: Encourage positions that favor fetal rotation and descent.

Problems with the Pelvis and Soft Tissues

  • Pelvic Structure: Gynecoid pelvis is optimal for vaginal delivery; soft tissue obstructions, like a full bladder, can complicate labor.

Psychological Factors and Prolonged Labor

  • Factors contributing to prolonged labor include:

    • Excessive pain without analgesic control.

    • Absence of support persons.

    • Immobility and restricted activities.

    • Increased anxiety leading to hormonal responses that lower contractility.

    • Nursing Interventions: Focus on energy conservation, comfort promotion, and emotional support.

Implications of Prolonged Labor

  • Potential complications include maternal/newborn infections, exhaustion, and increased postpartum hemorrhage risks.

Precipitate Birth

  • Definition: Birth concluding in under 3 hours with rapid contraction escalation.

  • Risks: Uterine rupture, cervical lacerations, potential for fetal distress due to oxygen compromise, and birth injuries such as intracranial hemorrhage.

Premature Rupture of Membranes (PROM)

  • Definition: Spontaneous rupture of membranes more than an hour before contractions start.

  • Diagnosis: Confirmatory testing involving observation for a “ferning” pattern in fluid.

Preterm Labor

Maternal Symptoms

  • Symptoms that may indicate preterm labor include uncomfortable or painless contractions, lower back aches, pelvic pressure, changes in discharge, and abdominal cramps.

Risk Factors

  • Factors influencing preterm labor vulnerability include underweight status, chronic conditions, hydration issues, and previous preterm births.

Prolonged Pregnancy

  • Definition: Duration exceeding 42 weeks potentially causing placental aging and inefficiency leading to fetal complications such as weight loss and low glucose levels.

  • Diagnostic Tests: Required assessments might include nonstress tests (NST), amniotic fluid index (AFI), biophysical profiles (BPP), and fetal kick counts to monitor fetal and maternal health status.