Chapter 27: Intrapartum Complications

Question 1

what is dysfunctional labor?

Answer 1

• lack of normal progress of cervical dilation, effacement, or descent
• may result from problems with powers of labor, passenger, passage, psyche, or combination of these
• often prolonged, but may be unusually short and intense
• an operative birth may be needed if dysfunctional labor does not resolve or fetal or maternal compromise occurs

Question 2

what is dystocia?

Answer 2

• a general term to describe any difficult labor or birth

Question 3

what are signs of compromise during a dysfunctional labor?

Answer 3

• nonreassuring FHR
• fetal acidosis
• meconium passage
• maternal exhaustion
• maternal infection

Question 4

problems of the powers that may result in dysfunctional labor

Answer 4

• ineffective uterine contractions
• ineffective maternal pushing

Question 5

explain how ineffective contractions can be a problem for dysfunctional labor

Answer 5

• good contractions are coordinated, strong, and frequent
• causes of ineffective contractions:
  
  • fatigue
  • bedrest
  • electrolyte imbalance
  • hypoglycemia
  • excessive analgesia/anesthesia
  • overdistention of the uterus from multiple gestation or hydramnios
• 2 patterns of ineffective uterine contractions:
  
  • hypotonic dysfunction
  • hypertonic dysfunction

Question 6

hypotonic contractions

Answer 6

• coordinated by too weak and infrequent to be effective
• usually occurs during the active phase of labor, when progress normally quickens
• uterine overdistention is assoc with this b/c the stretched uterine muscle contracts poorly
• comfortable but frustrating to laboring woman
• does not cause fetal hypoxia

Question 7

mgmt of hypotonic contractions

Answer 7

• administration of IV or oral fluids corrects maternal F&E imbalances or hypoglycemia
• change positions, esp upright positions
• stand or sit in warm shower
• manage pain: epidural blocks
• therapeutic communication to identify anxieties or beliefs about labor
• amniotomy
• oxytocin infusion

Question 8

for moms with hypotonic contractions:

what are the main risks assoc with amniotomy?

what are the main risks assoc with oxytocin infusion?

Answer 8

• amniotomy:
  
  • umbilical cord prolapse
  • infection
  • placental abruption
• oxytocin infusion:
  
  • reduced placental perfusion caused by excessive contractions

Question 9

hypertonic contractions

Answer 9

• more often affect women in early labor w/ their first baby
• contractions are uncoordinated and erratic, and they are painful but ineffective
• uterine resting tone is high
  
  • dec oxygenation impacts fetus and causes constant cramping
• woman becomes exhausted and anxious

Question 10

mgmt of hypertonic contractions

Answer 10

• warm shower: promotes relaxation and rest
• systemic analgesics/low dose epidural
• tocolytics: may reduce uterine resting tone and improve placental blood flow

Question 11

what are the causes of ineffective pushing?

Answer 11

• poor positioning
• fear
• no sensation or urge
• exhaustion
• analgesia or anesthesia
• afraid to “let go” of baby

Question 12

what are the interventions for ineffective pushing?

Answer 12

• “laboring down”: delayed pushing, so encourage the woman to wait until she feels the reflexive urge to push
  
  • also do not limit the length of the 2nd stage of labor
• upright positions
  
  • squatting
  • add gravity to the pushing effors
• “runners stance”
• education
• less anesthesia
• good coaching

Question 13

problems of passenger that may cause dysfunctional labor

Answer 13

• fetal size
• fetal presentation or position
• multifetal pregnancy
• fetal anomalies

Question 14

macrosomia

Answer 14

• greater than 8 lb 13 oz or 4000 g
• head or shoulders may not be able to adapt to the pelvis if they are too large: cephalopelvic disproportion (CPD)
• also distention of the uterus by the large uterus reduces the strength of contractions during and after birth

Question 15

shoulder dystocia

Answer 15

• EMERGENCY!
• delayed or difficult birth of the shoulders may occur as they become impacted above the maternal symphysis pubis
  
  • after the head is born, it retracts against the perineum: “turtle sign”
• more likely to occur when the fetus is large or the mother has diabete
• problem: head is born and chest is in vagina–>prevents breathing

Question 16

mgmt for shoulder dystocia

Answer 16

• try for vaginal delivery
  
  • but prepare for C/S
• McRobert’s maneuver: woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve somewhat
• suprapubic pressure: push the anterior fetal shoulder downward to displace it from above the mother’s symphysis pubis
• fundal pressure should NOT be used b/c we don’t want to push the shoulders even harder against the symphysis
• once infant is born, check clavicles for crepitus, deformity, and bruising
• timekeeper is essential

Question 17

mnemonic for shoulder dystocia

Answer 17

• H: call for Help
• E: Evaluate for Episiotomy
• L: Legs–McRobert’s Maneuver
• P: suprapubic Pressure
• E: Enter: rotational maneuvers
• R: Remove the posterior arm
• R: Roll the patient to her hands and knees

Question 18

rotation abnormalities that may lead to dysfunctional labor

Answer 18

• persistence of the fetus in occiput posterior (OP) or occiput transverse (OT)
  
  • these positions can prevent the cardinal movements of normal labor from occurring
• most fetuses that begin in occiput posterior rotate spontaneously to the occiput anterior (OA)–>promotes normal extension and expulsion of the head
• labor is longer or more uncomfortable if the fetus is in OP–>back pain b/c contractions is intense
• mgmt:
  
  • counterpressure of the sacrum
  • hands and knees
  • side lying
    
    • 2 above both tend to rotate toward the anterior uterus
  • lunge positioning: widens the pelvis

Question 19

deflexion abnormalities that may lead to dysfunctional labor

Answer 19

• poorly flexed fetal head presents a larger diameter to the pelvis that if flexed with the chin on the chest
  
  • vertex presentation: head diameter is smallest
  • military and brow presentations: head diameter is largest
  • face presentations: head diameter is similar to the vertex presentation but the maternal pelvis can be transversed only if the fetal chin is anterior

Question 20

breech presentation and how it may contribute to dysfunctional labor

Answer 20

• dilation and effacement are slower in breech b/c the buttocks and feet do not form a smooth, round dilating wedge like the head
• greatest risk: fetal head (largest part) is last to be born
  
  • by the time the lower body is born, the umbilical cord is well into the pelvis and may be compressed
    
    • shoulders, arms, and head must be delivered quickly so the infant can breathe
• normally an external cephalic version is performed to try to position the infant in cephalic position or a C/S is performed if the baby can’t be turned

Question 21

how does a multifetal pregnancy contribute to dysfunctional labor?

Answer 21

• multifetal pregnancy may lead cause dysfunctional labor b/c of uterine overdistention (–>hypotonic contractions) and abnormal presentation of the fetuses
• potential for fetal hypoxia is greater and risk of PPH is greater
• almost always C/S: esp if 3 or more fetuses
• monitor both babies FHR during labor and continue to monitor 2nd baby’s FHR once first baby is born (usually w/in 30 min of first)
• equipment necessary for each baby: radiant warmers, resuscitation equipment, meds, blankets, hats, ID materials

Question 22

fetal anomalies which can lead to dysfunctional labor

Answer 22

• hydrocephalus
• large fetal tumors
  
  • usually discovered by U/S
  • vaginal birth if possible but C/S is common

Question 23

what are problems with the passage that may lead to dysfunctional labor?

Answer 23

• small or abnormally shaped pelvis
• maternal soft tissue obstructions: like full bladder

Question 24

how can a woman’s psyche contribute to dysfunctional labor?

Answer 24

• if a woman’s perception of stress is high:
  
  • inc glucose consumption
  • inhibition of contractions
  • poor pushing as abdomen and pelvic muscles tighten
  • inc pain perception
• nursing measures:
  
  • develop trusting relationship
  • make environment comfortable by adjusting temp/light
  • promoting physical comfort like cleanliness
  • provide accurate info
  • implement pain mgmt

Question 25

prolonged labor

Answer 25

• guideline once in active labor:
  
  • 1.2 cm/hr dilation for nullipara
    
    • descend 1 cm/hr
  • 1.5 cm/hr dilation for parous woman
    
    • descend 2 cm/hr
• risks of prolonged labor:
  
  • maternal or neonatal infection
  • maternal exhaustion–>ineffective pushing
  • high levels of anxiety/fear during subsequent labor

Question 26

nursing measures for prolonged labor

Answer 26

• promote comfort, conservation of energy
• emotional support
• position changes that favor normal progress
• assess for infection
• observe fetus for signs of intrauterine infection or compromised fetal oxygenation

Question 27

precipitate labor

Answer 27

• one in which birth occurs w/in 3 hrs of its onset
  
  • instense contractions have abrupt onset
• risks:
  
  • placental abruption
  • fetal meconium
  • maternal cocaine use
  • PPH
  • low apgar scores for infant
  • fetal intracranial hemorrhage or nerve dmaage
  • fetal hypoxia
  • late decels and bradycardia

Question 28

nursing measures for precipitate labor

Answer 28

• promote fetal oxygenation and maternal comfort
  
  • side lying position: enhance blood flow and reduce aortocaval compression
  • administer O2 to mom
  • IV fluids for blood volume
  • stop oxytocin if being given and begin tocolytic
  • epidural analgesia may not be possible
  • opioid analgesia given close to birth–>resp depression
  • breathing techniques for comfort

Question 29

precipitate birth

Answer 29

• labor of any length that occurs when a trained attendant is not there to assist
• unexpected, sudden birth
• nurse should wear gloves and support infant’s body as it emerges
  
  • teach to pant b/w contractions
• prepare for ROM
• do not try to keep fetus from being delivered
• apply gentle pressure to fetal head upward
• infant: airway and warmth

Question 30

assessment for intrauterine infection

Answer 30

• fetal tachycardia may be first sign
• maternal temp: assess q2-4 h in normal labor and q2 h after membranes rupture
  
  • assess hourly if elevated over 100.4 deg F
• maternal pulse rate, respirations, and BP
  
  • assess at least hourly to identify tachycardia or tachypnea
• assess amniotic fluid for normal clear color and mild odor
  
  • yellow or cloudy color and foul odor–>infection

Question 31

interventions for intrauterine infection

Answer 31

• wash hands before and after each contact w/ all pts to reduce transmission of organisms
• limit vaginal exams
• maintain aseptic technique
• keep underpads as dry as possible to reduce the moist, warm environment that favors bacterial growth
• clean excess secretions from the vaginal area in a front to back direction to limit fecal contamination and promote the mother’s comfort

Question 32

assessment for maternal exhaustion

Answer 32

• many women begin labor w/ a sleep deficit b/c of fetal movement, frequent urination, and shortness of breath
  
  • as labor drags on, mother’s reserves are further depleted
• signs of excessive fatigue:
  
  • verbal expression of tiredness, fatigue, or exhaustion
  • verbal expression of frustration w/ a prolonged, unproductive labor
  • ineffectiveness of or inability to use coping techniques (such as patterned breathing) that she previously used effectively
  • changes in her pule rate, respiration, and BP

Question 33

interventions for conserving maternal energy

Answer 33

• reduce factors that interfere w/ a woman’s ability to relax:
  
  • lower lights
  • reduce noise
  • maintain a comfortable maternal temperature
• position woman to maintain comfort, promote fetal descent, and enhance fetal oxygenation
  
  • support w/ pillows to reduce muscle strain
  • help change positions frequently, like q30 min, to reduce muscle tension
• soothing back rub reduces muscle tension and dec fatigue
  
  • firm sacral pressure to reduce pain if the fetus is OP
  • use birthing ball or warmth
• maintain IV fluids
  
  • assess I&O to identify dehydration
    
    • dehydration may cause maternal fever
  • if not contraindicated, provide juice, lollipops, frozen juice bars to moisten her mouth

Question 34

PROM vs pPROM

Answer 34

• PROM: rupture of amniotic sac before true labor
  
  • normal if it occurs at term
• pPROM: preterm premature rupture of membranes (before 37 weeks)
• greatest newborn risks occur when birth occurs before completion of 34 weeks of gestation

Question 35

conditions assoc with PROM:

Answer 35

• chorioamniotis: fever and uterine tenderness
  
  • may be assoc with GBS, gonorrhea
• vaginal or cervical infections: gonorrhea, chlamydia, trichomonas, GBS
• weak amniotic sac
• previous preterm births
• fetal abnormalities or malpresentation
• incompetent cervix
• overdistention of the uterus
• recent sexual intercourse
• maternal stress

Question 36

complications of PROM

Answer 36

• chorioamnionitis: weaken the membrane and lead to rupture
  
  • characterized by maternal fever and uterine tenderness
  • most likely to precede births in infants born before 34 weeks
  • frequent performance of vaginal exams inc risk of infection
• oligohydramnios: membranes may continue to leak
  
  • umbilical cord compression, reduced lung volume, and deformities may result
• RDS: if preterm birth occurs, the infant is more likely to have RDS

Question 37

mgmt of PROM

Answer 37

• depends on gestation and whether evidence of infection or maternal/fetal compromise exists
• for a woman at or near term (36 weeks or more of gestation), PROM may herald the the imminent onset of true labor
  
  • often the cervix is soft, with some dilation and effacement
• if the fetus is less than 36 weeks or the woman’s cervix is not soft and favorable for labor induction, therapeutic mgmt is more complex

Question 38

how to determine the true membrane rupture

Answer 38

• urinary incontnence, inc vaginal discharge, or loss of mucous plug can make a woman think that her membranes have ruptures when they have not
• digital vaginal exam is avoided esp if gestation is preterm and no evidence of labor exists
  
  • instead, perform a sterile speculum exam to look for a pool of flui near the cervix and estimate dilation and effacement
  • pH swab or fern test may be done to verify fluid is amniotic
• perform tests to assess fetal lung maturity
• if near term, cervix is favorable, and & fetal lungs are mature, induce labor
  
  • if cervix is not favorable and no infection, start steroids and abx
• if preterm, risk vs benefit:
  
  • look at gestational age, amt of amniotic fluid remaining, fetal lung maturity
  • cerclage may be placed to prevent premature dilation
  • if no evidence of infection and fetal lungs are immature, then observe for infection and onset of labor
    
    • daily NSTs are performed to watch for FHR nonreactivity
  • steroids and abx given

Question 39

nursing considerations for PROM

Answer 39

• observe for signs of infection
• at home:
  
  • avoid sexual intercourse or insertion of anything into vagina
  • avoid breast stimulation if preterm b/c can release oxytocin and stimulate contractions
  • take temp 4x per day: report anything over 100.4 deg F
  • maintain any activity restrictions
  • note and report uterine contractions or a foul odor to vaginal drainage

Question 40

preterm labor

Answer 40

• 20th-37th week
• ADRs of prematurity:
  
  • cerebral palsy
  • developmental delay
  • hearing and vision impairment
• risk factors:
  
  • previous preterm delivery
  • multifetal pregnancy
  • use of assisted reproductive technology: including prematurity, C/S, infant disability

Question 41

associated factors of preterm labor

Answer 41

• maternal medical conditions: UTIs, infection of reproductive organs, dental disorders, preexisting and gestational diabetes,connective tissue disorders, chronic HTN, drug abuse
• conceptions enhanced by assisted reproductive technology
• present and past obstetrical conditions: short cervical length, multifetal gestation, preterm membrane rupture, preeclampsoa, bleeding disorders, or problems with placental implantation
• fetal conditions: growth retardation, inadequate amniotic fluid
• social and environmental factors: absent prenatal care, domestic violence, maternal smoking

Question 42

symptoms of preterm labor

Answer 42

• uterine contractions
• sensation that the baby is frequently “balling up”
• cramps similar to menstrual cramps
• constant low backaches
• sensation of pelvic pressure or feeling the baby is pushing down
• pain, discomfort, or pressure in vagina
• change or inc in vaginal discharge
• abdominal cramps w/ or w/o diarrhea
• sense of just feeling bad

Question 43

measures to prevent preterm labor

Answer 43

• reduce barriers and improve access to care
• assess for risk factors
• promote adequate nutrition
• promote smoking cessation
• teach women and their partners about subtle signs of preterm labor and ways in which they differ from normal pregnancy changes
• empower women and their partners to take an active approach to seeking care:
  
  • they should know the S/S of preterm labor

Question 44

how to predict preterm birth

Answer 44

• cervical length: <25 mm–>may allow organisms easier access to the uterus and may weaken membranes and cause rupture
• PPROM in previous birth
• fetal fibronectin (fFn): protein present in fetal tissues
  
  • normally found in cervical and vaginal secretions from 16-20 wks and again at or near term
  • if it appears to early, it suggests that labor may begin early
  • maternal or fetal infection may be present if the fFn is positive during midpregnancy
• maternal illness or infection

Question 45

stopping preterm labor

Answer 45

• first determine if any problems exist that contraindicate continuing the pregnancy including HTN, hypovolemia, cardiac dz, pyelonephritis, nonreassuring FHR
• identify and tx infections
  
  • amniocentesis can be done to obtain amniotic fluid for culture if chorioamnionitis is suspected b/c this infection would contraindicate stopping labor
  • cultures: require 24-48 hr to complete, so antiinfectives started as soon as cultures obtained
• limit activity: help them relax
• hydrate: dehydration can contribute to uterine irritability in some women
• tocolytics administered
• corticosteroids given to accelerate fetal lung maturity if birth before 34 weeks seems inevitable
  
  • can reduce incidence and severity of RDS and IVH in preterm infants
  • try to delay birth for 24 hr after start of corticosteroid therapy

Question 46

Magnesium sulfate

Answer 46

• tocolytic and used to manage pregnancy assoc HTN to prevent seizures
• loading dose: 4-6 g over 30 min
  
  • maintenance tocolysis: 1-4 g/hr
• nursing care:
  
  • assessment of DTRs
  • monitor that urine output is >30 mL/hr
  • monitor RR b/c can depress RR
  • EFM b/c reduce variability is common
  • monitor bowel sounds q4-8 hr b/c of smooth muscle in intestinal tract is relaxed as uterus is relaxed
  • SEs: lethargy, flushing, dizziness, visual blurring, nausea, weakness, sensation of heat
  • calcium gluconate is antidote

Question 47

corticosteroids

Answer 47

• beta/dexamethasone
  
  • betamethasone: 6 mg q12H times 4 doses
  • dexamethasone: IM 12 mg, 2 doses 24 hr apart
• delay birth 24 hr
• accelerates fetal lung maturity
  
  • indicated if gestation is b/w 24-34 weeks b/c of high incidence of RDS
• increase maternal glucose
• monitor V/S: fever and tachycardia may indicate infection assoc with steroid administration
  
  • assess lung sounds b/c steroids can cause fluid retention
  • assess for pain and burning on urination (UTI)

Question 48

Nursing Actions to care for early term and late preterm infants

Answer 48

• assess frequently for resp difficulty
• observe for feeding difficulties
• monitor frequently for temp instability
• educate parents

Question 49

post term

Answer 49

• lasts longer than 42 weeks
• cause of prolonged labor: miscalculation of estimated delivery date b/c woman has irregular periods or miscalculated her LMP
• complications:
  
  • placenta aging–>placental insufficiency (dec supply of O2 and nutrients to baby)
    
    • calcification and abruption can occur
    • may start to notice late decels or dec variability
  • oligohydramnios
    
    • cord compression can result from reduced fluid
  • passage of meconium–>RDS if aspirated
  • late growth retardation
  • loss of weight
  • large babies are a birthing risk: dysfunctional labor, PPH, shoulder dystocia

Question 50

placental abnormalities

Answer 50

• women w/ placental abnormalities may experience hemorrhage
  
  • placenta previa (abnormal implantation in lower uterine segment) is sometimes assoc with an abnormally adherent placenta (placenta accreta)
• strongest risk for placenta accreta is previous uterine surgery
  
  • may cause intrapartum hemorrhage or hemorrhage immediately after birth b/c the placenta does not separate cleanly, often leaving fragments behind that prevent full contraction
• placenta increta: placenta penetrates uterine muscle itself
• placenta percreta: placenta penetrates through entire uterine wall
• hysterectomy may be required if large portion of placenta is abnormally adherent

Question 51

causes of prolapsed cord

Answer 51

• high station with ROM
• small fetus
• breech presentation: esp footling breech
• transverse lie
• hydramnios

Question 52

nursing care w/ a prolapsed cord

Answer 52

• priority:
  
  • to relieve pressure on the cord
  • to inc fetal oxygenation
  • prompt delivery of the fetus
• get help
• steps:
  
  • position woman’s hips heigher than head: knee chest, trendelenberg, hips elevated w/ pillows in side lying position
  • maintain vaginal elevation while woman is transferred to OR: minimize cord compression from the hand that is elevating the presenting part
    
    • use a gloved hand to push the fetus up and off the cord
  • avoid or minimize manual palpation or handing of cord
    
    • do not try to replace cord or manipulate cord
  • U/S exam to confirm presence of FHR before C/S
  • while prepping for C/S, give woman 8-10 L/min of O2 by face mask
    
    • may use a tocolytic to inhibit contractions to inc placental blood flow and reduce pressure on fetus
    • warm, saline moistened towels slow cooling and drying of the cord

Question 53

3 variations of uterine rupture

Answer 53

• complete: direct communication exists b/w uterine and peritoneal cavities
• incomplete: rupture into peritoneum covering the uterus or into the broad ligament but not the peritoneal cavity
• dehiscence: partial separation of an old uterine scar
  
  • little or no bleeding may occur
  • rupture or “window” may be found incidentally in a subsequent C/S or surgery

Question 54

clinical manifestations of uterine rupture

Answer 54

• abdominal pain and tenderness: can be excruciating or it may not be severe if at the peak of contraction
  
  • feels as if something “ripped”
• labor progress may stop b/c the open area prevents efficient expulsion of the fetus
• chest pain, pain b/w scapulae, pain on inspiration
• hypovolemic shock caused by hemorrhage: tachycardia, tachypnea, hypoTN, pallor, cool/clammy skin
• rigid abdomen
• signs of impaired fetal oxygenation: late decels, reduced variability, tachy/bradycardia
• absent FHR
• fetus palpated outside the uterus–>fetus likely dead

Question 55

risk factors for uterine rupture

Answer 55

• high parity
• blunt abdominal trauma
• intense contractions
• cephalopelvic disproportion
• previous uterine surgery or C/S

Question 56

nursing care for uterine rupture

Answer 56

• monitor maternal and fetal V/S
• administer uterine stimulant drugs cautiously to reduce risk of excessive contractions
• prepare client for C/S
• provide emotional support for client and partner
• treat shock: replace fluids/blood

Question 57

anaphylactoid syndrome

Answer 57

• AKA amniotic fluid embolism
• occurs when amniotic fluid is drawn into the maternal circulation and carried to the woman’s lungs
  
  • fetal particulate matter (skin cells, vernix, hair, meconium) obstructs pulmonary vessels
  • abrupt respiratory distress, depressed cardiac function, circulatory collapse, DIC, and usually death result
    
    • can also cause sepsis, preeclampsia, and cardiac dz
• more likely if labor is very strong and high intrauterine pressure forces amniotic fluid into open uterine/cervical veins
• presents like a PE

Question 58

therapeutic mgmt of anaphylactoid syndrome

Answer 58

• CPR and support
• O2 with mechanical ventilation
• correction of hypoTN
• blood component therapy (ie fibrinogen, packed RBCs, platelets, FFP) to correct coagulation defects

Question 59

maternal cardiac arrest

Answer 59

• CPR in pregnancy:
  
  • left tilt or manual uterine displacement
  • compression placement elevated
  • AED use is the same, but remove fetal monitors
• perimortem C/S: 4 min after arrest