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

–   Palpate FHT’s,   NEVER ATTEMPT TO REPLACE CORD!

–   Give O2   per mask at 10 Liters

–   Cover exposed cord with sterile wet gauze

–   Stay with the patient and offer support

 

Amniotic Fluid Embolism

•      Escape of amniotic fluid into the maternal circulation  

–  usually enters maternal circulation through open sinus at placental site

•      Usually fatal to the Mother

–  amniotic fluid contains debris, lanugo, vernix, meconium, etc.

•      Signs and Symptoms:

–  dyspnea

–  chest pain

–  cyanosis

–  shock

•      Therapeutic Interventions:

–  Deliver the baby

–  Provide cardiovascular and respiratory support to Mom

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