Chapter 15 Complications of Labor and Birth

1
Chapter 15 Complications of Labor and Birth
2
Preterm Labor

• Associated factors
• Poor prenatal care
• Infections, including periodontal infections
• Nutritional status
• Sociodemographics
• (Contd)

3
Preterm Labor

• (Contd)
• Signs and symptoms
• Uterine cramping (menstrual-like cramps)
• Abdominal cramping (with or without nausea,
  vomiting, diarrhea)
• Any vaginal bleeding
• Clear or tan vaginal fluid leakage
• Vaginal or pelvic pressure
• Low back pain
• Thigh pain (intermittent or persistent)
• (Contd)

4
Preterm Labor

• (Contd)
• Assessment and management
• Fetal fibronectin may be present in vaginal
  fluid
• Stopping preterm labor
• Identifying and treating infection
• Ensuring hydration
• Restricting activity
• Tocolytic drugs table 15-1
• Communication to reduce maternal anxiety
• Fetal surveillance
• Promotion of fetal lung maturity
• Glucocorticoids 24-48 hrs before delivery
• Surfactant to newborn after delivery
• (Contd)

5
Preterm Labor

• (Contd)
• Nursing care and pharmacologic therapy
• accurate IO
• assessment for s/s of fluid overload and
  pulmonary edema
• Home care management

6
Premature Rupture of Membranes (PROM)

• Nitrazine paper test skill 15-1
• Management
• Bedrest with BRP
• Observe for infection (chorioamnionitis)
• Fetal surveillance
• Antibiotics
• Steroids (fetal lung maturity)
• Prepare for home management, if applicable

7
Dystocia (Dysfunctional Labor)

• Powers (uterine contractions) table 15-4
• Hypotonic dysfunction
• Hypertonic dysfunction
• Passage (pelvis)
• Abnormal size or shape
• (Contd)

8
Dystocia

• (Contd)
• Passenger
• Cephalopelvic disproportion (CPD)
• Fetal presenting part too large to pass through
  womans pelvis
• Abnormal fetal presentation
• Breech most common malpresentation fig 15-2
• Face/brow
• Persistent occiput posterior
• External version
• (Contd)

9
Dystocia

• (Contd)
• Psyche (psychologic factors)
• Fear of pain
• Nonsupport
• Embarrassment
• Violation of religious rituals

10
Induction and Augmentation of Labor

• Induction measures to initiate uterine
  contractions before they begin spontaneously
• Augmentation use of oxytocic drug after
  spontaneous but ineffective labor has begun
• Reasons for induction
• Maternal indications-infection, PROM, worsening
  medical conditions
• Fetal indications-IUGR, postterm, fetal demise
• Contraindications active genital herpes, CPD,
  umbilical cord prolapse, placenta previa,
  previous vertical c-s scar
• Methods of induction
• Cervical ripening Bishops score
• (Contd)

11
Induction and Augmentation of Labor

• (Contd)
• Nonpharmacologic methods
• stripping of membranes
• AROM
• mechanical dilators
• hygroscopic dilators such as Laminaria
• Pharmacologic methods
• Prostaglandin gel
• cytotec

12

• Oxytocin induction and augmentation
• Nursing care
• initial assessment of cervix for dilatation
  effacement, fetal presentation, position
  descent
• continuous fetal monitoring
• IV pump must be used
• assess for uterine hyperstimulation
  contraction lasting gt 90 secs and/or lt 60 sec
  apart or
• fetal distress
• If either occur stop the pitocin contact MD

13
Episiotomy

• Surgical incision made in perineum to permit
  easier passage of the fetus
• Midline
• Mediolateral
• Perineal lacerations

14
Assisted Vaginal Delivery

• Forceps fig 15-6
• Vacuum extraction fig 15-8
• Possible complications
• fetal edema bruising to scalp,
  cephalhematoma, scalp lacerations, subdural
  hematomas

15
Postterm Labor and Birth

• Maternal risks
• large newborn necessitating forcep assisted
  birth, lacerations of vagina, potential c-s
• Fetal risks
• birth trauma, CPD, hypoxia

16
Precipitate Labor

• Labor completed in less than 3 hours from onset
  of true labor to delivery of infant

17
Uterine Rupture

• Causes previous cesarean delivery aggressive or
  poorly supervised induction prolonged labor with
  CPD
• Signs and symptoms persistent UCs without
  periods of relaxation sharp pain in suprapubic
  area symptoms of shock fetal distress
• Treatment
• Immediate uterine surgery possible hysterectomy

18
Prolapsed Umbilical Cord

• Umbilical cord precedes fetal presenting part
• May be occult (hidden), inside vagina, or extend
  below vulva
• Contributing factors
• ROM before fetal engagement polyhydramnios
• Small fetus
• Breech presentation
• Transverse lie
• Unusually long cord
• Multifetal pregnancy
• (Contd)

19
Prolapsed Umbilical Cord

• (Contd)
• Nursing interventions
• Place womans hips higher than her head
• Push fetal presenting part away from cord
• Oxygen 8-10 L/min per face mask
• Closely monitor FHR by EFM
• Prepare for rapid vaginal delivery or cesarean
  section

20
Multifetal Pregnancy

• Preterm labor common
• Increased risk of postpartum hemorrhage
• Cesarean birth more common
• Twin-to-twin transfusion syndrome
• Multifetal pregnancy reduction
• Risk of disseminated intravascular coagulation
  (DIC)

21
Cesarean Birth

• Birth is accomplished through abdominal and
  uterine incision to preserve life or health of
  mother and/or fetus
• Indications box 15-1
• Surgical techniques
• Skin incisions transverse (Pfannenstiel) or
  vertical not indicative of uterine incision
• Uterine incisions lower segmentless risk of
  subsequent uterine rupture possibility of VBAC
• (Contd)

22
Cesarean Birth

• (Contd)
• Complications/risks
• maternal aspiration, PE, hemorrhage, UTI,
  wound infection
• fetal preterm newborn, fetal injuries,
  respiratory problems
• Preparation
• Nursing care box 15-2
• Preoperative
• Newborn
• Postoperative
• Vaginal birth after cesarean (VBAC)
• Trial of labor (TOL)
• Not indicated if previous fundal scar (classic
  CS) or evidence of CPD