Complications of Labor and Delivery

Dystocia - An abnormal, long, or difficult labor or delivery

COMPLICATIONS OF THE PSYCHE

• Etiology and Pathophysiology:

Hormones released in response to anxiety can cause DYSTOCIA

– Intense anxiety stimulates Sympathetic nervous system which releases catecholamines that lead to myometrial dysfunction.

– Norepinephrine and epinephrine lead to uncoordinated or increased uterine activity

· Nursing Care

– Assess support available and be there for the patient

– Patient Teaching- breathing/relaxation

– Provide with non-pharmacological measures

– Keep informed

– Provide quiet calm environment

HYPERTONIC UTERINE CONTRACTIONS

• Most often occur in first-time mothers, Primigravidas

• Contractions are ineffectual, erratic, uncoordinated, and involve only a portion of the uterus

• Increase in frequency of contractions, but intensity is decreased, do not bring about dilation and effacement of the cervix.

Signs and Symptoms:

1. PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain

2. Dilation and effacement of the cervix does not occur.

3. Prolonged latent phase. Stay at 2 - 3 cm. don’t dilate as should

4. Fetal distress occurs early– uterine resting tone is high, decreasing placental perfusion.

5. Anxious and discouraged

Treatment of Hypertonic Uterine Contractions

• Provide with COMFORT MEASURES

Warm shower; Mouth Care; Imagery; Music; Back rub

• Mild sedation

• Bedrest

• Hydration

• Tocolytics to reduce high uterine tone

HYPOTONIC UTERINE CONTRACTIONS
UTERINE INERTIA

• Etiology and Pathophysiology:

– Overstretching of the uterus --large baby, multiple babies, polyhydramnios, multiple parity

– Bowel or bladder distention preventing descent

– Excessive use of analgesia

• Signs and Symptoms of HYPOTONIC UTERINE INERTIA:

– Weak contractions – become mild

– Infrequent (every 10 – 15 minutes +) and brief,

– Can be easily indented with fingertip pressure at peak of contraction.

– Prolonged ACTIVE Phase

– Exhaustion of the mother

– Psychological trauma - frustrated

Therapeutic Interventions:

1. Ambulation – getting up and walking will increase contractions

2. Nipple Stimulation –causes release of endogenous Pitocin which can stimulate contractions

3. Enema--warmth of enema may stimulate contractions

4. AMNIOTOMY – artificial rupture of the membranes

• Advantages of doing this before Pitocin

– Contractions are more similar to those of spontaneous labor

– Usually no risk of rupture of the uterus

– Does not require as close surveillance

• Disadvantages of an Amniotomy

– Delivery must occur

– Increase danger of prolapse of umbilical cord

– Compression and molding of the fetal head (caput)

• Nursing Care:

– # 1-Check the fetal heart tones

– Assess color, odor, amount

– Provide with perineal care

– Monitor contractions

– Check temperature every 2 hours

5. Pitocin – for augmentation of labor

• Use only if CPD is not present

• Give 20 units / 1000 cc. fluid and hang as a secondary infusion, never as primary

GOAL:

Achieve contractions every 2 - 3 minutes of good intensity with relaxation between

• Nursing Care:

– Assess contractions--are they increasing but not tetanic

– Assess dilation and effacement

– Monitor vital signs and FHT’s

Prolonged Labor

Definition: A labor lasting more than 18-24 hours

Normally:

• Cervical dilation -- Primigravida 1.2 cm / hr. Multigravida 1.5 cm / hr

• Descent – 1 cm. / hr in primigravida and 2 cm./ hr. in multigravida

PRECIPITIOUS LABOR OR DELIVERY

• Labor that last less than 3 hours

• Unexpected fast delivery

• Etiology

– Lack of resistance of maternal tissue to passage of fetus

– Intense uterine contractions

– Small baby in a favorable position

• Complication:

– If the baby delivers too fast, does not allow the cervix to dilate and efface which leads to cervical lacerations

– Uterine rupture

– Fetal hypoxia and fetal intracranial hemorrhage

Rapid Delivery
Delivery Outside Normal Setting

• Everything is OUT OF CONTROL!

– mom is frightened, angry, feels cheated

• Nursing Care:

– Do NOT leave the mother alone

– Try to make the place clean, (don’t break down table)

– Try to get the mother in control -- Have mom pant to decrease the urge to push

– Apply gentle pressure to the fetal head as it crowns to prevent rapid change in pressure in the fetal head which can cause subdural hemorrhage or dural tears.

– Deliver the baby BETWEEN contractions to control delivery

– Suction or hold baby’s head low and place on mom/s abdomen, tie off cord

– Allow to breast feed, Document!

Pelvic Dystocia

• Definition:

– Pelvic Inlet or Outlet is not of sufficient size or proper shape to allow the baby to get through

• Etiology

– Congenital defect

– Malnutrition -- Rickets

– Neoplasms

– Fracture / Trauma

• Signs and Symptoms:

– Labor is arrested. Station does not decrease. Baby does not move down in the birth canal after long time in labor or with prolonged pushing.

• Therapeutic Interventions:

– cesarean delivery

Complications of the Passenger

• Malpositions:

– Posterior position--usually mom complains of back pain

• Treatment:

– Forceps -- low forceps or outlet forceps usually applied after crowning

– Vacuum extraction -- disk shaped cup placed over vertex of head and vacuum applied.

– Episiotomy - surgical incision to allow more room

• Malpresentation -- brow, face, transverse, breech

may allow to deliver vaginally with caution or Cesarean birth

• Treatment:

– May allow to deliver with caution or C-birth

– Version -- alteration of fetal position by abdominal or intrauterine manipulation

• Cephalopelvic Disproportion

– Large baby or small pelvis

– Usually diagnosed when there is an arrest in descent

– Station remains the same

• Treatment:

– Cesarean Delivery

• Multiple Fetus

– may be delivered by cesarean birth

–

CESAREAN DELIVERY

• OPERATIVE PROCEDURE IN WHICH THE FETUS IS DELIVERED THROUGH AN INCISION IN THE ABDOMEN

• REMEMBER -- IT IS A BIRTH !

• Mom may feel less than normal, so may need support

• May have option of a VBAC the next time

Premature Rupture of the Membranes / PROM

• Definition:

– Spontaneous rupture of the membranes

• Etiology

– Infections - Incompetent cervix

– Fetal abnormalities - Sexual Intercourse

• Major risk - ascending intrauterine infection

• Other risk -- Precipitation of labor

• Treatment and Nursing Care:

– Wait and watch, bedrest, no intercourse

– Betamethasone / Celestone -- provides stressor to the lungs of the fetus to stimulate production of surfactant

– Assess time membranes ruptures and if labor started

– Check temperature frequently

– Describe character of amniotic fluid

– Check WBC

– Provide psychological support

Preterm Labor

Definition:

– Labor that occurs after 20 weeks but before 37 weeks

Etiology:

– urinary tract infections

– Premature rupture of membranes

Goal -- STOP THE LABOR ! suppress uterine activity

Therapeutic Interventions:

§ Drug Therapy / Tocolytics

• Uses: Stop or arrest labor

• Criteria for use, don’t give if:

– Patient is in Active labor, cervix has dilated to 4 cm. or more

– Presence of Severe Pre-eclampsia

– Fetal complications / Fetal demise

– Hemorrhage is present

– Ruptured membranes

• Examples:

– Yutopar (ritodrine) or Brethine (terbutaline sulfate)

SIDE EFFECTS or WARNING SIGNS:

– Palpitations

– Tachycardia - pulse ~120

– Tremors, nervousness, restlessness

– Headache, severe dizziness

– Hyperglycemia

• TOXIC EFFECTS - PULMONARY EDEMA

- rales, crackles, dyspnea

- Must perform chest assessment with nursing assessment every shift

and chart lung sounds.

Nursing Care:

– Stop the medication

– Start oxygen

– Give ANTIDOTE: INDERAL

Patient Teaching:

– Teach how to take medication -- on time

– Teach patient to check pulse, call Dr. if > 120 – 140 (dehydration increases contractions)

– Teach to assess fetal movement daily, kick counts

– Drink 8-10 glasses of water per day

– Monitor uterine activity -- Home monitoring -- call dr. if has contractions

– Decrease activity

– Lie on side

– Keep bladder empty

Ruptured Uterus

• Spontaneous or traumatic rupture of the uterus

• Etiology:

– Rupture of a previous C-birth scar

– Prolonged labor

– Injudicious use of Pitocin -- overstimulation

– Excessive manual pressure applied to the fundus during delivery

• Signs and Symptoms:

– Sudden sharp abdominal pain, abdominal tenderness

– Cessation of contractions

– Absence of fetal heart tones

– Shock

• Therapeutic Interventions:

– Deliver the baby ! / Cesarean Delivery

Prolapse of the Umbilical Cord

Definition:

• Prolapse of the umbilical cord thorough the cervical canal along side of the presenting part

Etiology:

• Occurs anytime the inlet is not occluded. Fetus is not well engaged

• GOAL:

– RELIEVE THE PRESSURE ON THE CORD

– SUPPORT MOTHER AND THE FAMILY

• NURSING CARE / Therapeutic Interventions:

**Get the pressure off the Cord --place in trendelenberg or knee-chest position OR elevate part with sterile gloved hand

Complications of Labor and Delivery

COMPLICATIONS OF THE PSYCHE

• Etiology and Pathophysiology:

Hormones released in response to anxiety can cause DYSTOCIA

– Intense anxiety stimulates Sympathetic nervous system which releases catecholamines that lead to myometrial dysfunction.

– Norepinephrine and epinephrine lead to uncoordinated or increased uterine activity

· Nursing Care

– Assess support available and be there for the patient

– Patient Teaching- breathing/relaxation

– Provide with non-pharmacological measures

– Keep informed

– Provide quiet calm environment

HYPERTONIC UTERINE CONTRACTIONS

• Most often occur in first-time mothers, Primigravidas

• Contractions are ineffectual, erratic, uncoordinated, and involve only a portion of the uterus

• Increase in frequency of contractions, but intensity is decreased, do not bring about dilation and effacement of the cervix.

Signs and Symptoms:

1. PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain

2. Dilation and effacement of the cervix does not occur.

3. Prolonged latent phase. Stay at 2 - 3 cm. don’t dilate as should

4. Fetal distress occurs early– uterine resting tone is high, decreasing placental perfusion.

5. Anxious and discouraged

Treatment of Hypertonic Uterine Contractions

• Provide with COMFORT MEASURES

Warm shower; Mouth Care; Imagery; Music; Back rub

• Mild sedation

• Bedrest

• Hydration

• Tocolytics to reduce high uterine tone

HYPOTONIC UTERINE CONTRACTIONS UTERINE INERTIA

• Etiology and Pathophysiology:

– Overstretching of the uterus --large baby, multiple babies, polyhydramnios, multiple parity

– Bowel or bladder distention preventing descent

– Excessive use of analgesia

• Signs and Symptoms of HYPOTONIC UTERINE INERTIA:

– Weak contractions – become mild

– Infrequent (every 10 – 15 minutes +) and brief,

– Can be easily indented with fingertip pressure at peak of contraction.

– Prolonged ACTIVE Phase

– Exhaustion of the mother

– Psychological trauma - frustrated

Therapeutic Interventions:

1. Ambulation – getting up and walking will increase contractions

2. Nipple Stimulation –causes release of endogenous Pitocin which can stimulate contractions

3. Enema--warmth of enema may stimulate contractions

4. AMNIOTOMY – artificial rupture of the membranes

• Advantages of doing this before Pitocin

– Contractions are more similar to those of spontaneous labor

– Usually no risk of rupture of the uterus

– Does not require as close surveillance

• Disadvantages of an Amniotomy

– Delivery must occur

– Increase danger of prolapse of umbilical cord

– Compression and molding of the fetal head (caput)

• Nursing Care:

– # 1-Check the fetal heart tones

– Assess color, odor, amount

– Provide with perineal care

– Monitor contractions

– Check temperature every 2 hours

• Use only if CPD is not present

• Give 20 units / 1000 cc. fluid and hang as a secondary infusion, never as primary

GOAL:

Achieve contractions every 2 - 3 minutes of good intensity with relaxation between

• Nursing Care:

– Assess contractions--are they increasing but not tetanic

– Assess dilation and effacement

– Monitor vital signs and FHT’s

• Cervical dilation -- Primigravida 1.2 cm / hr. Multigravida 1.5 cm / hr

• Descent – 1 cm. / hr in primigravida and 2 cm./ hr. in multigravida

PRECIPITIOUS LABOR OR DELIVERY

• Labor that last less than 3 hours

• Unexpected fast delivery

• Etiology

– Lack of resistance of maternal tissue to passage of fetus

– Intense uterine contractions

– Small baby in a favorable position

• Complication:

– If the baby delivers too fast, does not allow the cervix to dilate and efface which leads to cervical lacerations

– Uterine rupture

HYPOTONIC UTERINE CONTRACTIONS
UTERINE INERTIA

Rapid Delivery
Delivery Outside Normal Setting