Complication o Labor

Prolapsed Cord

Umbilical cord precedes presenting part

May be visible or occult

More common withAbnormal lie

Low birth weight

> previous births

Amniotomy

Long cord

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Prolapsed Cord

Key interventionsRelieve 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

Prolapsed Cord

Maternal RiskNo direct risk

Fetal-Neonatal RiskCord compression ↓O2 possible death or neurologic compromise

TxPrevention!

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

Umbilical Cord Abnormalities

2 vessel cord: associated with abnormalities, esp kidney

Check for 3 vessels at time of birth (2 arteries 1 vein)

Amniotic Fluid-Related Complications

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

Amniotic Fluid-Related Complications

Hydramnios: >2000mL of fluidCause unknown but associated with congenital abnormalities (swallowing/voiding problems); also diabetes, Rh sensitization, infections such as CMV, Rubella, syphilis, toxoplasmosis, herpesIf severe (>3000mL) may experience severe edema, hypotension (from vena cava compression) and pain

TxSupportiveCorrective: may do amniocentesis, Indocin (to ↓ fetal urine output)

Amniotic Fluid-Related Complications

Oligohydramnios<500mL fluid or largest pocket of fluid on U/S is <5cmAssociated 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:MonitorAmnioinfusionFetal surgery

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

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

Intrauterine Fetal Demise (IUFD)

Provide privacy for familiesListenAvoid inappropriate consolationsGive accurate infoObtain mementosAllow opportunity to see and holdProvide information re: burial optionsProvide 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

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 testsAssist with examination and specimen collectionAdminister IV FluidsObserve for initiation of labor Offer emotional supportTeach the patient with a history of PROM how to recognize it and to report it immediately

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Signs of Preterm LaborRhythmic 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

Birth Related Procedures

Procedures

VersionExternalInternal

Cervical RipeningCervidilCytotec

Amnioinfusion~250-500 mL warmed saline or LR is infused into uterus via IUPC over 20-30 minUsed to correct variables, dilute mec stained fluid

Labor Induction

Stimulation of U/C before spontaneous onset of labor

Prior to starting inductionVerification of gestation age

Confirmation of fetal presentation

Assessment of risk factors

Well-being assessment of mom and baby

Cervical Assessment

Labor Induction

Cervical Assessment (Bishop’s Score)

Higher the score, more successful the induction will be

Favorable cervix is most important criteria for successful induction

Bishop’s 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

Labor InductionMethods

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

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

EpisiotomyMidline

from vag orifice to fibers of rectal sphincterLess blood loss, easier to repair, heals with less discomfort

MediolateralFrom midline of posterier forchette to 45° angle to right or leftProvides more room but has > blood loss, longer healing time and more discomfort

TxPain relief measuresIceInspect!

Operative Assisted Deliveries

ForcepsMaternal complications

TraumaIncreased pain in pp periodWeakening of the pelvic floor

Fetal-neonatal complicationsCaputCaphalohematomaTransient facial paralysistrauma

Operative Assisted DeliveriesVacuum Extractor

Longer duration of suction, more likely scalp injuryMaternal complications

Perineal traumaEdemaGenital tract and anal sphincter probs (< than with forceps)

Neonatal complicationsScalp lacerationsBruising/subdural hematomaCephalohematomaJaundiceFx clavicleRetinal hemorrhagedeath

Cesarean Birth1970 - ~5%1988 – 24.7%2001 – 21%2005 - ? But higherIndications

Failure to progress/descendPrevia/abruption/prolapse cordNon-reassuring fetal statusMalpresentationPrevious C/S

Maternal morbidity and mortality is > than vag delivery

Cesarean Birth

TechniqueNOTE: 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 symphysisAdv: quicker, more room

Disadv: scar obvious, longer

Cesarean Birth

Cesarean Birth

Cesarean Birth

TechniqueUterine incision (type depends on need for C/S)

Transverse-lower uterine segmentAdv: 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

Cesarean Birth

TechniqueLower 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

Cesarean Birth

TechniqueClassic incision

Upper uterine segment

Adv: more room, quicker to do

Disadv: more blood loss, difficult to repair, higher risk of rupture in subsequent pregnancies

Cesarean Birth

Prep for C/S (time dependent)Permits NPO

IV Oral/IV antacids, H2 inhibitors

Foley Teaching

Shave

Immediate PP careFreq vs (q 5-10 min) Lungs

Check dressing I&O

Lochia and uterus Anesthetic level

VBAC (vaginal birth after cesarean)

That was then, this is now

Specific criteria

Must sign consent

ContraindicationsClassic incision or previous fundal uterine surgery

Most common risk is hemorrhage and uterine rupture

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.

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.

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.

Deep attachment to uterine wall

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.