Complicated Labor Patterns Complications of Labor

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Complicated Labor Patterns Complications of Labor
Delivery

• NUR 264

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If was not supposed to be hard work, it would not
have been called LABOR. Anonymous
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Characteristics of Tachysystole Labor

• Increase contraction frequency
• lt 2 min frequency, gt 90 seconds duration
• Decrease contraction intensity
• Increase uterine resting tone gt 20 mm Hg
• Prolonged latent phase
• Painful due to uterine
• muscle anoxia
• Ineffective in dilating and
• effacing cervix

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Implications of Tachysystole Labor (contd)

• Maternal exhaustion, dehydration, infection
• Reduced uteroplacental exchange resulting in
  nonreassuring fetal status
• Prolonged pressure on fetal head resulting in
• Excessive molding
• Caput succedaneum
• Cephalhematoma

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Effects of labor on the fetal head. A, Caput
succedaneum formation. The presenting portion of
the scalp area is encircled by the cervix during
labor, causing swelling of the soft tissue. B,
Molding of the fetal head in cephalic
presentations (1) occiput anterior, (2) occiput
posterior, (3) brow, (4) face.
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Nursing Plan for Tachysystole Labor

• Stop oxytocin
• Increase IV rate
• Administer O2 by face mask
• Position in side-lying position
• Provide support and encouragement
• Monitor contractions and fetal status
• Notify health care provider
• Assist with amniotomy
• Administer pharmacologic agents as ordered
  sedation
• Monitor maternal fatigue

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Hypotonic Labor

• lt 2 to 3 contractions in 10 minutes
• Causes
• Fetal macrosomia
• Multiple gestation
• Hydramnios
• Grand multiparity
• CPD

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Implications of Hypotonic Labor

• Help with coping abilities
• Prolonged labor results in
• Maternal exhaustion, dehydration
• Increased incidence of infection
• Postpartum hemorrhage due to uterine atony
• Nonreassuring fetal status
• Fetal sepsis from pathogens ascending from birth
  canal

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Nursing Plan for Hypotonic Labor

• Frequent monitoring of vital signs, FHR and
  contractions
• Assist with amniotomy assess amniotic fluid for
  meconium
• Administer oxytocin or nipple stimulation
• Assess bladder for distention and empty every 2
  hours
• Minimize vaginal exams to decrease risk of
  infection

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Nursing Plan for Hypotonic Labor (contd)

• Assess for signs of infection
• Maternal fever
• Chills
• Foul-smelling amniotic fluid
• Fetal tachycardia
• Provide emotional support
• Provide information and encourage questions
• Prepare for surgical delivery

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Abnormal Presentation/Dystocia

• Abnormal flexion of head, breech, twins
• Large fetus macrosomia
• CPD, shoulder dystocia
• Poor quality contractions
• - prolonged labor
• Extensive perineal laceration at birth (3rd or
  4th degree) or vaginal trauma
• Increased fetal morbidity and mortality

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Abnormal Presentations
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Breech Presentations

• Likely cesarean birth
• Increased risk of prolapsed cord
• Increased risk of cervical spinal cord injuries
  due to hyperextension of fetal head during
  vaginal birth
• Increased risk birth trauma (especially head)
  during any type of birth

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Breech Presentations
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Multiple Gestation

• Frequent assessment of fetal heart tones of each
  fetus
• Education of mother about signs and symptoms of
  preterm labor
• Encouragement of mother to rest frequently prior
  to birth
• Preparation of equipment needed to care for each
  individual newborn

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Multiple Gestation
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Multiple Gestation
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Cephalopelvic Disproportion

• Occurs when fetal head is larger than maternal
  pelvic diameter
• Lack of fetal descent in presence of strong
  contractions
• Labor usually prolonged

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Cephalopelvic Disproportion (contd)

• Increase pelvic diameter during labor by
  squatting, sitting, rolling from side to side,
  maintaining knee-chest position, use of a labor
  ball - AVOID lithotomy!
• Vaginal birth may be possible depending upon type
  of CPD
• CPD may make cesarean only available method of
  birth

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Fetal Macrosomia

• Newborn weighing more than 4500 g or more
• May be postterm, IDM
• Identification of fetal macrosomia is conducted
  through
• Palpation of fetus in utero
• Ultrasound of fetus
• X-ray pelvimetry
• Shoulder Dystocia

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Management of Fetal Macrosomia

• Continuous fetal monitoring if labor is allowed
  to progress
• Requires notification of health care provider for
  early decelerations, labor dysfunction, or
  nonreassuring fetal status
• McRoberts manuever legs to chest suprapubic
  pressure
• Cesarean birth performed if fetus is greater than
  4500 g

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Shoulder Dystocia
McRoberts Maneuver
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Care of Mother

• Care of mother after birth of newborn with
  macrosomia requires
• Fundal massage to prevent maternal hemorrhage
  from overstretched uterus
• Close monitoring of vital signs and vaginal blood
  flow

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Care of Newborn

• Care of newborn with macrosomia requires
  assessment of newborn for
• Cephalhematoma
• Erb's palsy
• Fractured clavicles
• Anoxia
• Cord prolapse

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Implications of Hydramnios

• Rh sensitization
• Malformations of fetal swallowing
• Neural tube defects with exposed meninges
• Anencephaly
• Cardiac anomalies
• Esophageal or duodenal atresia
• Provide information and emotional support

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Nursing Plan for Oligohydramnios

• Reduced AFI
• Evaluate EFM tracing for variable decels or
  nonreassuring fetal status
• Reposition mother to relieve cord compression
• Notify clinician of signs of cord compression
• Evaluate newborn
• Anomalies of skin skeleton, adhesions
• Pulmonary hypoplasia
• Renal agenesis, lower UTI obstructive lesions
• Postmaturity

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Cord Prolapse

• Umbilical cord precedes fetal presenting part
  placing pressure on cord and diminishing blood
  flow to fetus
• Bed rest is recommended if engagement has not
  occurred and membranes have ruptured
• Assess for nonreassuring
• fetal status

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Cord Prolapse

• Examiners fingers must remain in vagina
• Have patient assume knee-chest position,
  Trendelenburg position, or side-lying position
  with hips elevated on pillow (head/chest up if
  epidural)
• Apply O2 at 8 10 L/min
• Vaginal birth may be attempted if completely
  dilated and pelvic measurements adequate
• Cesarean section is delivery of choice

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Precipitous Delivery

• Precipitous birth is one that occurs rapidly
  without physician or certified nurse-midwife in
  attendance
• Mother may fear what is going to happen and feel
  that everything is out of control
• Mother needs to assume comfortable position

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Precipitous Delivery (contd)

• Nurse scrubs his or her hands if time permits
  applies gloves
• When infant's head crowns, mother should pant
• Gentle pressure is applied against fetal head to
  prevent it from popping out rapidly
• Perineum is supported and head is born between
  contractions

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Postterm Pregnancy

• Postterm pregnancy may result in an increased
  possibility of
• Probable labor induction
• Forceps or vacuum-assisted or cesarean birth
• Decreased perfusion to the placenta
• Decreased amount of amniotic fluid and possible
  cord compression
• Meconium aspiration
• Macrosomia or a loss of fat and muscle mass
  resulting in small-for-gestational age (SGA)
  newborn

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TABLE 213 Placental and Umbilical Cord
Variations
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TABLE 213 (continued) Placental and
Umbilical Cord Variations
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Manual Removal of Placenta
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Amniotic Fluid Embolism

• Amniotic fluid fetal cells enter bloodstream
• Triggers immune response similar to anaphylactic
  shock
• Results in pulmonary artery vasospasm, pulmonary
  hypertension, hypoxia
• Then hemorrhage and DIC

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S/S of Amniotic Fluid Embolism

• Sudden onset resp. distress - dyspnea
• Cyanosis
• Frothy sputum
• Chest pain, cor pulmonale
• Tachycardia, severe hypotension
• Mental confusion
• Massive hemorrhage, DIC, shock
• Coma and maternal death
• Fetal death if birth not immediate

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Nursing Plan for Amniotic Fluid Embolism

• Summon emergency team
• Positive pressure oxygen delivery
• Large bore IV
• CPR as needed
• Prepare for cesarean, if birth has not occurred
  and neonatal resuscitation
• Prepare for CVP line insertion
• Administer blood, hypotensive drugs, steroids
• 85 maternal survivors and 50 fetal survivors
  have neuro damage

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Birth-related Procedures
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Vacuum Extractor

• Assists birth by applying suction to fetal head
• Should be progressive descent with first two
  pulls, procedure should be limited to prevent
  cephalhematoma - Risk increases if birth not
  within six minutes
• Increases risk for jaundice - Due to reabsorption
  of bruising at cup attachment site

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Vacuum extractor traction. A, The cup is placed
on the fetal occiput and suction is created.
Traction is applied in a downward and outward
direction. B, Traction continues in a downward
direction as the fetal head begins to emerge from
the vagina. C, traction is maintained to lift the
fetal head out of the vagina.
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Risks of Forceps

• Monitor FHR during procedure
• Assess newborn for
• Bruising
• Edema
• Facial lacerations
• Cephalhematoma
• Transient facial paralysis
• Cerebral hemorrhage

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Risks of Forceps (contd)

• Empty bladder prior to procedure
• Assess patient for
• Vaginal or perineal lacerations
• Infection secondary to lacerations
• Increased bleeding
• Bruising
• Perineal edema
• Bladder injuries

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Application of forceps in occiput anterior (OA)
position. A, The left blade is inserted along the
left side wall of the pelvis over the parietal
bone. B, The right blade is inserted along the
right side wall of the pelvis over the parietal
bone. C, With correct placement of the blades,
the handles lock easily. During uterine
contractions, traction is applied to the forceps
in a downward and outward direction to follow the
birth canal.
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Indications for Cesarean Section

• Most common indications for cesarean birth
• Fetal distress
• Active genital herpes
• Multiple gestation (three or more fetuses)
• Umbilical cord prolapse
• Tumors that obstruct birth canal
• Lack of labor progression
• Maternal infection
• Pelvic size (cephalopelvic) disproportion
• Placenta previa or abruptio placenta
• Previous cesarean section
• Fetal malpresentation

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Preparation for C/S

• Preparation for cesarean birth requires
• Obtaining consent
• Obtaining V/S and FHR
• Establishing IV lines
• Inserting indwelling urinary catheter
• Performing abdominal prep
• Maintaining NPO status
• Administering preop
• medications

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Teaching C/S

• Teaching needs include
• What to expect before, during, and after delivery
• Why is it being done
• What sensations will the patient experience
• Role of significant others
• Turn, cough, deep breathe instruction
• Early ambulation
• Interaction with newborn

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Pfannenstiel Classical Incision
Incision
increased risk of uterine rupture in subsequent
pregnancies and labor.
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Nursing Care C/S

• Routine postpartal care including
• V/S and Fundus checks
• Care of incision
• Monitoring intake and output
• Maintain IV access
• Administer and teach about post-op medications
• Assessment of respiratory system
• Assessment of bowel sounds

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Vaginal Birth After Cesarean Birth

• Can occur after trial of labor in cases of
  nonrecurring indications for cesarean birth
• Most common risks are
• Hemorrhage
• Surgical injuries
• Uterine rupture
• Infant death or neurological complications
• Classic or T uterine incision is contraindication
  to VBAC

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Nursing Care for VBAC

• Continuous EFM or Internal Fetal and Uterine
  Monitoring
• IV fluids
• Avoid oxytocin if at all possible
• Important for nurse to support couple, explore
  their feelings, and provide information
  throughout labor

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Fetal Demise/Stillbirth

• Results from three factors
• Fetal factors
• Has or develops disorder incompatible with life
• Maternal factors
• Has disorder such as diabetes or preeclampsia
  that creates hostile environment for fetus
• Placenta or other factors
• Certain conditions such as abruptio placenta or
  cord accident cut off blood supply to fetus,
  leading to death

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Diagnosis of Fetal Loss

• Diagnosis may be made when mother notices lack of
  movement in fetus or at regularly scheduled
  physician's visit when fetal heart tone cannot be
  found

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Nursing Care - Fetal Loss

• Nursing care involves supporting family through
  grief work
• Assist family through labor and birth
• Provide for woman's physical needs after birth
• Encourage family members to express and share
  their thoughts and feelings about loss
• Give family an opportunity to view, hold, name
  infant

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Nursing Care Fetal Loss (contd)

• Nursing care involves supporting family through
  grief work
• Prepare items for family to keep to remember
  infant
• Provide opportunities for religious or spiritual
  counseling and cultural practices
• Visit or phone family after discharge to assist
  in closure
• Make referral to appropriate perinatal loss
  counseling services if indicated

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NCLEX Question

• Nursing assessment of a labor patient includes
  BP 116/72, P 88, contractions q 2 to 3 minutes,
  duration 75-80 seconds, resting tone not
  returning to baseline, FHR 150-156 bpm w/
  moderate variability. Which nursing action is
  appropriate?
• continue present rate of oxytocin
• decrease rate of oxytocin
• discontinue oxytocin administration
• increase rate of oxytocin

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NCLEX Question

• During the delivery, the fetal shoulders become
  stuck behind the symphysis pubis. What
  intervention can the nurse perform to assist with
  the delivery?
• uterine fundal pressure
• McRoberts maneuver
• McDonalds procedure
• vacuum suction

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NCLEX Question

• The nurse assesses uterine contractions as q 1
  11/2 minutes frequency and 30 second resting
  period during an oxytocin induction. Which is the
  priority nursing action?
• increase intravenous rate
• reposition client to side lying
• notify health care provider
• discontinue oxytocin

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NCLEX Question

• A laboring client is admitted with vaginal
  bleeding. Which interventions does the nurse
  perform? Select all that apply.
• Obtain fetal heart rate
• Perform vaginal exam
• Start intravenous infusion
• Obtain vital signs
• Begin oxytocin infusion
• Administer oxygen

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NCLEX Question

• Upon rupture the client has an excessive amount
  of amniotic fluid. What problem would the nurse
  assess the newborn for?
• Respiratory distress
• Fractured clavicle
• Cephalohematoma
• Esophageal atresia

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Intrapartum Nursing Diagnoses

• Fatigue related to inability to relax and rest
  amb hypertonic labor pattern
• Acute pain related to womans inability to relax
  amb hypertonic uterine contractions
• Ineffective individual coping related to
  ineffectiveness of breathing techniques to
  relieve discomfort amb irritability
• Anxiety related to slow labor progress amb
  hypotonic contractions

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Intrapartum Nursing Diagnoses

• Acute Pain related to uterine contractions amb
  complaints of 10/10 pain scale
• Ineffective individual coping related to
  unanticipated discomfort and slow progress in
  labor amb verbalizations

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