Complications During Labor & Birth Flashcards
The Five P’s
Powers
Passage
Passenger
Position
Psyche
Dysfunctional labor
Ineffective uterine contractions
Maternal bearing down efforts
Powers
Alterations in pelvic structure
Passage
Fetal causes (size, presentation, anomalies, etc.)
Passenger
Maternal position during labor/birth
Position
Psychological repsonses
Psyche
Abnormal uterine contractions that prevent dilation, effacement, or descent
dysfunctional uterine contractions
Usually occurs in latent (early) labor, primary dysfunctional labor
Painful, frequent contractions w/o cervical change (dilation)
Tx: Therapeutic Rest (narcotic, e.g.; Morphine)
Hypertonic uterine contraction
Usually occurs in active labor, secondary inertia
Weakening or cessation of uterine contractions
Tx: Ambulation, oxytocin augmentation, amniotomy, etc.
Hypotonic uterine contractions
Long, difficult, or abnormal labor
dystocia
-Contractures or narrowing of pelvic diameter
-Inadequate pelvis
-Placenta, fibroids, cervical edema
Pelvic and Anatomical Dystocia
-Anomalies (anencephaly)
-CPD (cephalopelvic disproportion)
-Malposition (LOP, ROP)
-Malpresentation (breech)
-Multifetal pregnancy
Fetal causes for dystocia
Inadequate pelvis
doesn’t allow fetus to get through the birth canal
Absence of a major portion of the brain, skull, scalp
Anencephaly
If the baby is facing forward and slightly to theleft(looking toward the mother’s right thigh) it is in theleftocciput posterior (LOP) position. This presentation can lead to
more back pain (sometimes referred to as “back labor”) and slow progression of labor.
Large baby due to
-Hereditary factors
-Diabetes
-Postmaturity (still pregnant after the due date has passed)
-Multiparity (not the first pregnancy)
True or False
Staying in one position can slow down fetal decent
True
What is Cephalopelvic disproportion (CPD)?
(CPD)occurs when a baby’s head or body is too large to fit through the mother’s pelvis. It is believed that true CPD is rare, but many cases of “failure to progress” during labor are given a diagnosis of CPD. If women is diagnosed in active labor then we will prep to go to OR for C-section
True or False
Hormones and neurotransmitters released in response to stress/anxiety (i.e. catecholamines) can cause dystocia.
True
Fetal Macrosomia
Birth weight
4,000-4,500g or 8.8-10 lbs
Shoulder dystocia can lead to
asphyxia
Maternal risks associated with post term pregnancy, labor, & birth after 42 weeks gestation
-Dysfunctional labor
-Interventions more likely necessary
-Birth canal trauma (macrosomia)
-Postpartum hemorrhage
-Infection
-Psychological reactions and fatigue
Fetal risks associated with post term pregnancy, labor, & birth after 42 weeks gestation
-Shoulder dystocia (macrosomia) –> Asphyxia
-Aging placenta –> oxygenation
-Oligohydramnios –> risk of cord compression
-Meconium aspiration
If a patient does not experience spontaneous labor by the 42nd week (sometimes earlier), __________ is considered the primary medical management choice
induction
Why is continuous fetal monitoring needed w/ induction?
-Amniotic fluid decreases in the post term pregnancy. Careful monitoring and interventions likely.
-At risk for variable decelerations: Low amniotic fluid (oligohydramnios)
-At risk for late decelerations: Aging placenta/uteroplacental insufficiency.
The use of chemical or mechanical modalities to initiate uterine contractions (before their spontaneous onset) to bring about childbirth
This is considered when an existing maternal or fetal condition dictates the need for medical intervention
Induction of labor
Infection of placenta and amniotic fluid (most often caused by bacteria from vagina, if membranes rupture)
Chorioamnionitis
Indications for induction
-Post-term pregnancy
-Maternal medical conditions (e.g., diabetes mellitus, renal disease, chronic pulmonary disease, chronic/gestational hypertension, preeclampsia, eclampsia)
-Premature rupture of membranes (PROM) (> 37 weeks gestation)
-Fetal demise
-Placental abruption
-Chorioamnionitis
-Fetal compromise (e.g., severe fetal growth restriction, isoimmunization, or oligohydramnios)
Contraindications for induction
cephalopelvic disproportion, non-reassuring FHR, placenta previa, prior uterine incision, active genital herpes, cervical cancer
Used to stimulate uterine contractions after labor has begun spontaneously but is not progressing satisfactorily. It is most commonly indicated for the management of hypotonic uterine dysfunction.
Augmentation of labor
Chemical methods used to soften cervix (effacement)
Prostaglandin E2 (Cervidil), placed posterior cervix
Prostaglandin E1 (misoprostol (Cytotec)) administered PO or placed posterior cervix
Induction & augmentation methods
Oxytocin (Pitocin) IV (stimulate contractions)
Nipple stimulation: releases oxytocin
Amniotomy: Artificial Rupture of Membranes (AROM)
Patient Position Change
Rotate Baby/Pressure on Cervix
Sweeping a finger over the membranes that connect the amniotic sac to the wall of the uterus, this will release prostaglandins which will soften the cervix and cause contractions
Stripping the membranes
If we notice FHR patterns that are abnormal, but don’t require emergent C-section we will …
stop the Pitocin
When theballooninflates inside thecervix, it puts pressure on thecervicalcells, helping it dilate and increasing the tissue’s response to oxytocin and prostaglandins
Cook cervical ripening balloon
AROM
Artificial rupture of the membranes
Labor typically begins within __________ hours after the membranes rupture.
12
Nursing interventions for AROM
-Record baseline FHR prior to, continuously during, and after due to risk of cord prolapse or infection
-Assess amount, color, consistency, odor of amniotic fluid
-Implement peri care and change pads for comfort
-Monitor temp every 2 hours
Intrauterine infusion of isotonic solution (0.9% sodium chloride or lactated Ringer’s)
Used to reduce severity of variable decelerations caused by cord compression
amniofusion
Indications for forceps assisted delivery
-Poor progress during second stage
-Fetal distress
-Persistent occiput posterior position
-Abnormal presentation
Nursing interventions for forceps assisted delivery
-Assess neonate for intracranial hemorrhage, fetal
bruising, and facial palsy
-Check FHR before forceps are applied and immediately after the forceps application
Indications for vacuum assisted delivery
-Maternal exhaustion and ineffective pushing
-Fetal distress during the second stage of labor
Nursing interventions for vacuum assisted delivery
-Place patient in lithotomy position and support with position
-Assess and record FHR before and during vacuum application
-Document number of pulls, pressure, and pop offs
-Observe neonate for bruising and caput succedaneum
Vacuum assisted delivery may cause the baby to have
swelling, bruising, and cephalohematoma
The observance of a pregnant patient and fetus for a reasonable period (approx. 4-6 hours) of spontaneous active labor to assess safety of vaginal birth for mother and infant.
Trial of labor (TOL)
Indications for TOL
-Maternal pelvis is of questionable size or shape
-Fetus is in an abnormal presentation
-If patient wants a vaginal birth after a previous c-section (VBAC)
The birth of a fetus through a trans-abdominal incision of the uterus
Purpose if to preserve the life or health of the mother and her fetus
cesarean section
Indications for C-section
-Previous C-section
-Failure to progress in labor
-Fetal factors: malpresentation, fetal distress, CPD, multiple fetuses, macrosomia, prolapsed cord
-Maternal factors: positive HIV, active genital herpes
-Placenta previa or abruption
C-section types (surgical techniques)
-Classical (Vertical Uterine Incision: Cannot have TOLAC)
-Low-Transverse (Horizontal Uterine Incision)
Once a classical C-section …
always a classical C-section
Nursing interventions for C-section
-Obtain informed consent
-Perform preoperative assessment and surgical checklist
-Administer preoperative medications
-Insert IV and foley
-Perform postoperative and postpartum assessment
-Assess for bleeding at site and lochia
-Obtain postop VS
-Monitor for effects of anesthesia
-Assess pain
Risk of uterine rupture after C-section?
Less than 1%
TOLAC
Trial of labor after cesarean
VBAC
Vaginal birth after cesarean
Requirements for TOLAC/VBAC
-Previous low transverse uterine incision
- <2 previous C/S
-Adequate pelvis
-No other uterine scars
-No history of uterine rupture
-Baby must be in VTX (cephalic) position
-CTOL (Cleared for Trial of Labor)
A tear in the wall of the uterus that may involve all layers. Rare, but serious obstetrical emergency
Rupture of the uterus
Rupture of uterus causes
Causes:
-Separation of scar from previous cesarean incision
-Uterine trauma
-Drug use
-Congenital uterine abnormality
Causes During Labor:
-Intense spontaneous uterine contractions (prev. c/s)
-Labor stimulation (oxytocin, prostaglandin)
-Over-distended uterus
-Malpresentation
-External or internal version
-Difficult forceps birth
Head is born, but the anterior shoulder cannot pass under the pubic arch
-Turtle Sign
Head emerges and it retracts against the perineum and external rotation does not occur
Potential Causes:
Excessive fetal size (>4000 grams/8.8lbs), Maternal pelvic abnormalities, CPD
Shoulder dystocia
Occurs when the cord lies below the presenting part of the fetus
Contributing factors:
Long umbilical cord (approx. >100cm)
Malpresentation (breech, transverse lie)
Unengaged presenting part (negative station)
Risks:
Fetal hypoxia resulting from cord compression
Variable Decelerations
Prolapsed umbilical cord
Nursing intervention for prolapsed umbilical cord
Insert hand into vagina and hold the presenting part off the cord. Do not take hand out until baby is delivered!
Occurs when amniotic fluid containing particles of debris (i.e. vernix, hair, skin cells, or meconium) enters the maternal circulation and causes the release of endogenous mediators.
Rare: Mortality Rate as high as 80%: Survival- Most mothers and approx. 50% of infants suffer neurological impairment.
Signs: Acute dyspnea, Severe hypotension, If mother survives, hemorrhage/DIC usually occurs
Risk Factors:
Fetal death, Multiparity, Placental Abruption, Macrosomia
Amniotic fluid embolism
Life threatening complications that can occur with amniotic fluid embolism
breathing problems, cardiac arrest, and excessive bleeding
The cessation of cardiac activity from conception to 28 days following birth.
Perinatal loss
IUFD
Intrauterine Fetal Demise/Death
FDIU
Fetal Demise/Death In Utero
Causes of perinatal loss
-Maternal Factors (diabetes, HTN, infection)
-Fetal Anomalies
-Asphyxia by Cord Compression (Cord Accident)
-Placental Insufficiency
-Perinatal loss may occur intrapartum or postpartum due to an obstetrical emergency
Treatment for perinatal loss (ways to deliver fetus)
Dependent on gestational age
-D&C
-Induction
Avoid C-section
Nursing management for perinatal loss
-Admit patient away from audible laboring mothers
-Label hospital door with appropriate demise sticker
-Patient is active member in plan of care
-Continuum of care
-Assess coping abilities
Phrases to avoid using w/ perinatal loss
“It’s God’s will.”
“You can always have another.”
“There was a problem with this baby.”
“There’s always next time.”
It is acceptable to say “I’m Sorry”, hold their hand and mourn with them.
