Complication o Labor

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Complication o Labor
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Prolapsed Cord

• Umbilical cord precedes presenting part
• May be visible or occult
• More common with
• Abnormal lie
• Low birth weight
• gt previous births
• Amniotomy
• Long cord

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Prolapsed Cord

• Key interventions
• Relieve pressure on cord
• Trendelberg or knee chest position
• Oxygen to increase maternal oxygen saturation
• Pressure on the presenting part
• Call for help, but do not leave mother
• Expedite delivery

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Prolapsed Cord

• Maternal Risk
• No direct risk
• Fetal-Neonatal Risk
• Cord compression ? ?O2 ? possible death or
  neurologic compromise
• Tx
• Prevention!
• If palpated, keep pressure off cord
• ?When ROM occurs, listen to FHTs for full minute
  if decel heard, do vag exam to r/o cord prolapse

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Umbilical Cord Abnormalities

• 2 vessel cord associated with abnormalities, esp
  kidney
• Check for 3 vessels at time of birth (2 arteries
  1 vein)

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Amniotic Fluid-Related Complications

• Embolism bolus of amniotic fluid enters
  maternal circulation then lungs.
• OB emergency!
• High mortality.

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Amniotic Fluid-Related Complications

• Hydramnios gt2000mL of fluid
• Cause unknown but associated with congenital
  abnormalities (swallowing/voiding problems)
  also diabetes, Rh sensitization, infections such
  as CMV, Rubella, syphilis, toxoplasmosis, herpes
• If severe (gt3000mL) may experience severe edema,
  hypotension (from vena cava compression) and pain
• Tx
• Supportive
• Corrective may do amniocentesis, Indocin (to ?
  fetal urine output)

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Amniotic Fluid-Related Complications

• Oligohydramnios
• lt500mL fluid or largest pocket of fluid on U/S
  is lt5cm
• Associated with postmaturity, IUGR, major renal
  problem in fetus (malformation, blockage)
• If occurs early in preg, may cause fetal
  adhesions also fetal skin and skeletal
  abnormalities may occur, pulmonary hypoplasia,
  cord compression
• Tx
• Monitor
• Amnioinfusion
• Fetal surgery

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Complications of 3rd and 4th stage

• Retained placenta
• ?Lacerations cervical or vaginal suspected when
  bright red bleeding in presence of well
  contracted uterus
• 1st degree fourchette, perineal skin, vag
  mucousa
• 2nd degree perineal skin, vag mucosa, underlying
  fascia, muscles of perineal body
• 3rd degree extends thru perineal skin, vag
  mucosa and perineal body and involves anal
  sphincter
• 4th degree same as 3rd degree, but extends thru
  rectal mucosa to the lumen of the rectum

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Intrauterine Fetal Demise (IUFD)

• May be found prior to coming to hosp or at time
  of admission
• May be unexplained or r/t materanal disease
  process or fetal insult
• May be induced right away or wait for spontaneous
  labor. C/S not automatically done
• Pain med give freely

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Intrauterine Fetal Demise (IUFD)

• Provide privacy for families
• Listen
• Avoid inappropriate consolations
• Give accurate info
• Obtain mementos
• Allow opportunity to see and hold
• Provide information re burial options
• Provide support information

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Premature Rupture of Membrane(PROM)

• Spontaneous break in the amniotic sac before
  onset of regular contractions
• Mother at risk for chorioamnionitis, especially
  if the time between Rupture of Membranes (ROM)
  and birth is longer than 24 hours
• Risk of fetal infection, sepsis and perinatal
  mortality increase with prolonged ROM.
• Vaginal examinations or other invasive procedure
  increase risk of infection for mother and fetus.

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PROMSigns of Infection

• Maternal fever
• Fetal tachycardia
• Foul-smelling vaginal discharge

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PROM Detecting Amniotic Fluid

• Nitrazine
• Ferning Place a smear of fluid on a slide and
  allow to dry. Check results. If fluid takes on a
  fernlike pattern, it is amniotic fluid.
• Speculum exam

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fernlike pattern
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PROM Treatment

• Depends on fetal age and risk of infection
• In a near-term pregnancy, induction within 12-24
  hours of membrane rupture
• In a preterm pregnancy (28 -34 weeks), the woman
  is hospitalized and observed for signs of
  infection. If an infection is detected, labor is
  induced and an antibiotic is administered

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PROMNursing Interventions

• Explain all diagnostic tests
• Assist with examination and specimen collection
• Administer IV Fluids
• Observe for initiation of labor
• Offer emotional support
• Teach the patient with a history of PROM how to
  recognize it and to report it immediately

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Signs of Preterm Labor

• Rhythmic uterine contraction producing cervical
  changes before fetal maturity
• Onset of labor 20 37 weeks gestation.
• Increases risk of neonatal morbidity or mortality
  from excessive maturational deficiencies.
• There is no known prevention except for treatment
  of conditions that might lead to preterm labor.

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Treatment of Preterm Labor

• Used if tests show premature fetal lung
  development, cervical dilation is less than 4 cm,
  there are no that contraindications to
  continuation of pregnancy.
• Bed rest, drug therapy (if indicated) with a
  tocolytic

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Preterm Labor Pharmacotherapies

• Terbutaline (Brethine), a beta-adrenergic
  blocker, is the most commonly used tocolytic
• Side effects maternal fetal tachycardia,
  maternal pulmonary edema, tremors, hyperglycemia
  or chest pain, and hypoglycemia in the infant
  after birth
• Ritodrine (Yutopar) is less commonly used.

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Preterm Labor Pharmacotherapies

• Magnesium Sulfate
• Acts as a smooth muscle relaxant and leads to
  decreased blood pressure
• Many side effects including flushing, nausea,
  vomiting and respiratory depression
• Should not be used in women with cardiac or renal
  impairment
• Excreted by the kidneys

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Perterm Labor Pharmacotherapies

• Corticosteroids
• Help mature fetal lungs
• Betamethasone or dexamethasone
• Most effective if 24 hours has elapsed before
  delivery

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Nursing Interventions with Preterm Labor

• Nursing Intervention in Premature labor
• Observe for signs of fetal or maternal distress
• Administer medications as ordered
• Monitor the status of contractions, and notify
  the physician if they occur more than 4 times per
  hour.

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Nursing Interventions with Preterm Labor

• Nursing Intervention in Premature labor
• Encourage patient to lie on her side
• Bed rest encouraged but not proven effective
• Provide guidance about hospital stay, potential
  for delivery of premature infant and possible
  need for neonatal intensive care

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Nursing Interventions with Preterm Labor

• Discharge teaching for home care
• Avoid sex in any form
• Take medications on time
• Teach to recognize the signs of preterm labor and
  what to do

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Birth Related Procedures
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Procedures

• Version
• External
• Internal
• Cervical Ripening
• Cervidil
• Cytotec
• Amnioinfusion
• 250-500 mL warmed saline or LR is infused into
  uterus via IUPC over 20-30 min
• Used to correct variables, dilute mec stained
  fluid

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Labor Induction

• Stimulation of U/C before spontaneous onset of
  labor
• Prior to starting induction
• Verification of gestation age
• Confirmation of fetal presentation
• Assessment of risk factors
• Well-being assessment of mom and baby
• Cervical Assessment

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Labor Induction

• Cervical Assessment (Bishops Score)
• Higher the score, more successful the induction
  will be
• Favorable cervix is most important criteria for
  successful induction

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Bishops Score)
Cervical dilatation 1-2 3-4 5-6
Cervical effacement 0-40 40-80 80
Position of cervix posterior medial Anterior
Consistency of cervix Firm Medium soft
Station of presenting part -2 -1/0 1/2
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Labor Induction

• Methods
• Stripping membranes
• Oxytocin
• ?Always given via IV pump (may be given IM after
  del)
• Site closest to insertion
• Continuous EFM
• Risks
• Hyperstimulation
• Uterine rupture
• Water intoxication
• Fetal risks associated with maternal problems,
  hyperbilirubinemia, trauma from rapid birth

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Episiotomy

• Decline over the years
• May make it more likely will have deep tears
• Lacerations heal more quickly in absence of epis
• 3rd or 4th degree lacerations more likely with
  epis

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Episiotomy

• Midline
• from vag orifice to fibers of rectal sphincter
• Less blood loss, easier to repair, heals with
  less discomfort
• Mediolateral
• From midline of posterier forchette to 45 angle
  to right or left
• Provides more room but has gt blood loss, longer
  healing time and more discomfort
• Tx
• Pain relief measures
• Ice
• Inspect!

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Operative Assisted Deliveries

• Forceps
• Maternal complications
• Trauma
• Increased pain in pp period
• Weakening of the pelvic floor
• Fetal-neonatal complications
• Caput
• Caphalohematoma
• Transient facial paralysis
• trauma

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Operative Assisted Deliveries

• Vacuum Extractor
• Longer duration of suction, more likely scalp
  injury
• Maternal complications
• Perineal trauma
• Edema
• Genital tract and anal sphincter probs (lt than
  with forceps)
• Neonatal complications
• Scalp lacerations
• Bruising/subdural hematoma
• Cephalohematoma
• Jaundice
• Fx clavicle
• Retinal hemorrhage
• death

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Cesarean Birth

• 1970 - 5
• 1988 24.7
• 2001 21
• 2005 - ? But higher
• Indications
• Failure to progress/descend
• Previa/abruption/prolapse cord
• Non-reassuring fetal status
• Malpresentation
• Previous C/S
• Maternal morbidity and mortality is gt than vag
  delivery

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Cesarean Birth

• Technique
• NOTE Skin incision NOT indicative of uterine
  incision
• Transverse (Pfannenstiel)-lower uterine segment
• Adv below pubic hair line, less bleeding, better
  healing
• Disadv difficult to extend if needed, requires
  more time, if adipose fold difficult to keep
  clean and dry
• Vertical-between naval and symphysis
• Adv quicker, more room
• Disadv scar obvious, longer

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Cesarean Birth
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Cesarean Birth
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Cesarean Birth

• Technique
• Uterine incision (type depends on need for C/S)
• Transverse-lower uterine segment
• Adv thinnest ? less blood loss, only mod
  dissection of bladder, easier to repair, site
  less likely to rupture during subsequent
  pregnancies, less chance of adherence of bowel or
  omentum to incision line
• Disadv takes longer, limited in size due to
  major blood vessels, greater tendency to extend
  into uterine vessels

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Cesarean Birth

• Technique
• Lower Uterine Segment Vertical Incision
• Preferred for multiple gestation, abnormal
  presentation, previa, preterm, macrosomia
• Adv more room
• Disadv may extend into cx, more extensive
  dissection of the bladder is necessary, if
  extends upward hemostasis and closure more
  difficult, higher risk of rupture in subsequent
  pregnancies

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Cesarean Birth

• Technique
• Classic incision
• Upper uterine segment
• Adv more room, quicker to do
• Disadv more blood loss, difficult to repair,
  higher risk of rupture in subsequent pregnancies

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Cesarean Birth

• Prep for C/S (time dependent)
• Permits NPO
• IV Oral/IV antacids, H2 inhibitors
• Foley Teaching
• Shave
• Immediate PP care
• Freq vs (q 5-10 min) Lungs
• Check dressing IO
• Lochia and uterus Anesthetic level

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VBAC (vaginal birth after cesarean)

• That was then, this is now
• Specific criteria
• Must sign consent
• Contraindications
• Classic incision or previous fundal uterine
  surgery
• Most common risk is hemorrhage and uterine rupture

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Placental accreta

•  occurs when the placenta attaches too deep in
  the uterine wall but it does not penetrate the
  uterine muscle. Placenta accreta is the most
  common accounting for approximately 75 of all
  cases.
•  Approximately 1 in 2,500 pregnancies experience
  placenta accreta, increta or percreta.
• There are two further variants of the condition
  that are known by specific names and are defined
  by the depth of their attachment to uterine wall.

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Placental increta

• occurs when the placenta attaches even deeper
  into the uterine wall and does penetrate into the
  uterine muscle. Placenta increta accounts for
  approximately 15 of all cases.

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Placental percreta

• occurs when the placenta penetrates through the
  entire uterine wall and attaches to another organ
  such as the bladder. Placenta percreta is the
  least common of the three conditions accounting
  for approximately 5 of all cases.

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Deep attachment to uterine wall
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management

• Treatment Managing placenta accreta requires
  controlling hemorrhaging removing the placenta
  that has adhered to the uterine wall is very
  difficult and can result in blood loss. If the
  diagnosis is made before labor begins, a cesarean
  section should be performed whenever possible and
  blood products should be readily available
• In the majority of cases, a hysterectomy remains
  the treatment of choice.

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