LABOR COMPLICATIONS

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LABOR COMPLICATIONS

• Anna Mae Smith, MPAS, PA-C
• Lock Haven University
• Physician Assistant Program

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Dystocia/CPD

• Dystocia Laboring patient is not making any
  progress at cervical dilatation /or fetal
  descent during the active phase of labor
• CephaloPelvic Disproportion head fails to come
  down into the pelvis with full dilation of cervix

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Causes of Dystocia

• Not in labor!
• Dysfunctional labor
• CPD causes
• Persistent occiput posterior (OP) presentaion
• Fetal macrosomia
• Pelvis
• Fetal malpresentations
• Congenital anomalies (hydrocephalus)

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Pelvic Types and Characteristics
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Management

• Amniotomy
• Pitocin
• Possible C-section

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Shoulder Dystocia

• The anterior shoulder gets caught above the pubic
  symphysis
• Common in macrosomia
• Diabetics
• Maternal obesity
• Post dates pregnancy

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Shoulder Dystocia Complications

• Maternal lacerations hemorrhage
• Fetal Brachial plexus injury (Erbs Palsy)
  adduction internal rotation of the shoulder
  flaccid paralysis of the affected arm(Waiters
  tip hand)
• Fx clavicle
• C-spine
• Asphyxia of the infant

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Chorioamnionitis

• Preterm labor with intact mambranes
• Maternal infection/sepsis/endometritis
• Neonatal Sepsis
• Diagnosis
• Fever
• Uterine tenderness
• Fetal tachycardia
• Foul-smelling amniotic fluid

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PROM

• Must deliver within 24hrs or greatly increased of
  infection!!
• If premature may gain time with antibiotics

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ACTIVE PHASE COMPLICATIONS

• Hypertonic dysfunction contractions that are
  generated in the lower pole of the uterus or in
  multiple sites
• Hypotonic dysfunction
• An insufficient generation of action potentials
  from the myometrial pacemaker
• Inadequate propagation of the signal throughout
  the myometrium
• Lack of mechanical response to the signal
• In either circumstance, the contraction pattern
  fails to result in cervical effacement and
  dilatation.

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Primary Dysfunctional Labor

• Active-phase dilatation that occurs at a rate
  less than the 5th percentile
• This value is 1.2 cm/hr in nulliparas and 1.5
  cm/hr in multiparas
• Tx of above hypo/hypertonic dysfunction is
  oxytocin

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Labor Induction

• Maternal indications
• Fetal demise
• Severe hypertensive disease
• Other medical problems (DM, renal, pulm)
• Risk of precipitous labor or distance from
  hospital

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Labor Induction

• Fetal Indications
• Post-term pregnancy
• Maternal HTN
• DM
• PROM
• Chorioamnionitis
• Oligohydramnios
• IUGR
• Rh sensitization

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Relative Contraindications to Labor Induction

• Placenta previa
• Abnormal lie or presentation
• Prior classic incision
• Active genital herpes
• Pelvic abnormalities
• Invasive cervical cancer
• Presenting part above pelvic inlet

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Induction Methods

• Membrane Stripping
• Amniotomy
• Pitocin
• Vaginal prostaglandins

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Complications with second stage of Labor

• Full dilation to delivery of the infant
• Problems are caused by protraction or arrest of
  descent
• Check forhypotonic dysfunction, overdistended
  bladder, strong perineal resistance, conduction
  anesthesia, or ineffectual bearing down
• May require forceps, vacuum extractor or
  C-section

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Prerequisites for Forceps Delivery

• The membranes must be ruptured.
• The cervix must be fully dilated.
• The operator must be fully acquainted with the
  use of the instrument.
• The position and station of the fetal head must
  be known with certainty.
• Adequate maternal anesthesia for proper
  application of the forceps must be present.

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Prerequisites for Forceps Delivery

• 6. The maternal pelvis must be adequate in size
  for atraumatic delivery.
• 7. The characteristics of the maternal pelvis
  must be appropriate for the type of delivery
  being considered.
• 8. The fetal head must be engaged.

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Vacuum Extractor

• Mom requires less anesthesia
• Similar outcomes to forceps

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Complications of the Third Stage

• Interval between delivery of the infant
  delivery of the placenta
• Placenta will come out on own in 10-15 mins after
  baby!
• Dont interfererisk uterine inversion
  hemorrhage!

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Placenta is ready..have mom push one more time!

• (1) a gush of blood from the vagina
• (2) descent of the umbilical cord
• (3) a change in shape of the uterine fundus from
  discoid to globular
• (4) an increase in the height of the fundus as
  the lower uterine segment is distended by the
  placenta
• INSPECT the PLACENTA!!