Chapter+10

Chapter 10: Complications of Labor and Birth

Authors

  • Roberta F. Durham, RN, PhD
  • Liujing Chen, RN, BSN

Learning Outcomes

  • Describe the primary causes of dystocia and the related nursing and medical care.
  • Demonstrate understanding of knowledge related to induction of labor and augmentation of labor and vaginal birth after cesarean birth.
  • Identify potential complications of dystocia in labor and related medical and nursing care.
  • Identify and manage high-risk pregnancy, labor, and delivery to promote healthy outcomes for the mother and infant.
  • Describe the key obstetrical emergencies and the related medical and nursing care.

Introduction

  • Most pregnant women go into labor spontaneously, experiencing a normal labor and spontaneous vaginal birth.
  • Interventions to initiate or accelerate labor and birth are increasingly common.
  • Nurses have a key role in identifying complications and implementing nursing actions to achieve a safe birth, improving maternal and neonatal outcomes.
Components of Labor and Birth Complications
  • Labor and birth complications can necessitate various interventions.
  • Risks include maternal/fetal injury during high-risk delivery.
  • Relevant nursing diagnoses and outcomes are integral to care planning.

Dystocia

  • Defined as difficult labor, colloquially referred to as "failure to progress."
  • Types of dystocia include:
    • Uterine dystocia (e.g., hypertonic or hypotonic uterine dysfunction)
    • Precipitous labor
    • Fetal dystocia
    • Pelvic dystocia
Uterine Dystocia

  • Hypertonic Uterine Dysfunction

    • Characterized by frequent and painful contractions that are ineffective for cervical dilation and effacement.
    • Nursing interventions include:
    • Evaluate the cause of labor dysfunction.
    • Hydrate the woman to improve uterine perfusion and coordination.
    • Provide pain management to facilitate rest and avoid exhaustion.
    • Offer emotional support.

  • Hypotonic Uterine Dysfunction

    • Occurs when contraction pressure is insufficient for cervical dilation and effacement.
    • Nursing interventions include:
    • Augment labor with oxytocin.
    • Perform amniotomy.
    • Provide emotional support.
    • Encourage ambulation.
    • Ensure hydration.
Precipitous Labor
  • Defined as labor lasting fewer than 3 hours from onset to birth.
  • Risk factors may include grand multiparity and history of precipitous labor.
  • Nursing considerations involve:
    • Remaining in the room with the woman.
    • Monitoring fetal heart rate (FHR) and uterine contractions (UC).
    • Providing support and preparing for delivery.
Fetal Dystocia
  • Causes may include excessive fetal size, malpresentation, multiple pregnancies, or fetal anomalies.
  • Assess fetal position using Leopold's maneuver and alert the care provider if abnormal.
Pelvic Dystocia
  • Defined as a small or abnormally shaped pelvis.
  • Nursing interventions include:
    • Performing sterile vaginal examination (SVE) to evaluate labor progress and fetal descent into the pelvis.

Labor Interventions

  • Induction of Labor

    • Indications: Maternal or fetal conditions warranting labor induction, gestational age considerations, and cervix/pelvic assessment (should be over 39 weeks if elective).

  • Cervical Ripening

    • Methods of cervical ripening include:
    • Mechanical methods (e.g., balloon catheters).
    • Pharmacological methods (e.g., Cervidil, Cytotec).

  • Pharmacological Augmentation

    • Use of medications to strengthen and regulate contractions and shorten labor duration.

Oxytocin Induction

  • Used effectively to initiate contractions and augment labor (considered a high-alert medication).
  • Administration rate to be guided by physician/certified nurse midwife (CNM) protocol and careful assessment of contractions.
  • Risks include:
    • Tachysystole, decreased placental perfusion, and non-reassuring fetal status.
Nursing Management during Oxytocin Infusion
  • Includes careful titration based on maternal-fetal response, adjusting dosage rates according to fetal and uterine activity:
    • Decrease dosage if contractions are too frequent.
    • Discontinue medication for abnormal fetal status or excessive uterine activity.
    • Increase dosage for inadequate labor progress.
Goals of Nursing Care during Induction
  • Informed Consent: Acquire consent prior to procedure.
  • Assess FHR and UCs continuously.
  • Monitor vital signs.
  • Optimize contraction patterns (aiming for every 2-3 minutes, lasting 40-60 seconds).
  • Track cervical changes and fetal descent.
  • Document key events on the electronic fetal monitor (EFM) strip and in the patient chart.

Complications of Labor Induction

  • Tachysystole: Defined as excessive uterine activity, characterized by:
    • More than five contractions in 10 minutes (average over 30 minutes).
    • Additional features of excessive activity include:
    • Contractions lasting 2 minutes or longer.
    • Intra-amniotic pressure exceeding 25 mm Hg between contractions.
Operative Vaginal Delivery
  • Vacuum-Assisted Delivery: Use of a vacuum cup on the fetal head to assist delivery.
    • Advantages over forceps include ease of application, reduced anesthesia needs, and lower risk of maternal soft tissue damage.
  • Forceps Delivery: Involves a tool to assist with fetal head delivery, requiring complete cervical dilation, ruptured membranes, and engaged fetal head.

Vaginal Birth After Cesarean (VBAC)

  • Definition: Trial of Labor After Cesarean (TOLAC) refers to a planned attempt at vaginal delivery by a woman with a previous cesarean history.
  • Risks and Benefits:
    • Concerns include risk of uterine rupture and potential fetal death, but benefits comprise shorter hospital stays and fewer complications.
  • Management: Similar to that for women undergoing vaginal deliveries; vigilant monitoring of uterine activity and FHR is crucial.

Obstetric Complications

  • Complications can arise suddenly, without prior warning or risk factors; more often, they result from pregnancy-related or pre-existing conditions.
Common Complications

  • Preeclampsia and diabetes are relevant pregnancy-related conditions.

    • Post-Term Pregnancy and Birth:

  • Defined as reaching or exceeding 42 weeks' gestation.

  • Maternal Risks:

    • Dysfunctional lab