Childbirth At Risk Labor Related Complications
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Transcript Childbirth At Risk Labor Related Complications
Childbirth At Risk
Labor Related Complications
Chapter 21
Heather Bailey, RN, BSN
Psychologic Disorders
Characterized by alterations is thinking,
mood or behavior
Depression, bipolar disorder, anxiety,
phobias, obsessive-compulsive disorder,
posttraumatic stress disorder, schizophrenia
and mental retardation
Nursing Care
Decrease anxiety
Assist with coping
Keep oriented to reality
Promote optimal functioning
Increased need for teaching
Dysfunctional Labor
Dystocia
Hypertonic Labor
Hypotonic Labor
Precipitous Labor
Hypertonic Labor
Ineffective contraction of poor quality,
increased resting tone
Contractions are painful but ineffective to
progress labor
Attempt to make the labor more functional
Keep the woman as comfortable as possible,
help her to cope
Hypotonic Labor
Less than 2-3 contractions in a 10 minute
period
Happens with an overstretched uterus,
bowel or bladder distention and CPD
Active management of labor
Help the woman cope with a long labor
Precipitous Labor
Labor that lasts less than 3 hours and results in
rapid birth
Multiparity, large pelvis, previous precipitous
labor and/or small fetus in favorable position
(preterm)
Assist the woman to cope, be prepared for birth at
any time
Discontinue oxytocin with accelerated labor
pattern
Postterm Pregnancy
Greater than 42 weeks complete weeks
gestation
Not common but there are many risks
associated with postterm pregnancy
Risks of Postterm Pregnancy
Labor induction
Large-for-gestational age
infant or Intrauterine
Growth Restriction
Operative vaginal delivery
Cesarean birth
Increased psychological
stress
Decreased placental
perfusion
Oligohydramnios
Meconium aspiration
Fetal trauma
Non reassuring fetal
status
Postterm Care
Closely monitor FHR for non reassuring
fetal status
Monitor after rupture of membranes for
meconium
Prepare for infant resuscitation after birth
Fetal Malposition
Occiput posterior position
Persistent occiput posterior position
Monitor labor for progress
Change position frequently, hand/knees is
helpful to help rotate the fetus to occiput
anterior position
Prepare for forceps to be used to rotate the
fetal head
Fetal Malpresentation
Brow
Face
Breech
Transverse lie
Brow Presentation
Forehead of the fetus is the presenting part
Occurs more often in multipara
Possible due to lax abdominal and pelvic
muscles
Least common type of malpresentation
Risks/Nursing Care
Maternal: prolonged labor, cesarean birth,
Fetal: cerebral and neck compression,
damage to the trachea and larynx, facial
edema, bruising
Frequent position changes
Face Presentation
Face of the fetus is the presenting part
Occurs most frequently in multiparas,
preterm birth and presence of anencephaly
Risks/Care of Face
Presentation
Maternal:
– Increased risk of CPD
– Prolonged labor
– Cesarean birth
Fetal:
– Cephalohematoma of the face
– Edema of face and throat
– Pronounced molding of the head
Care is the same as for brown presentation
Breech Presentation
Frequently associated with preterm birth,
placenta previa, hydramnios, multiple
gestation, uterine anomalies and fetal
anomalies
Types:
– Frank
– Incomplete (footling)
– Complete
Risks/Care
Prolapsed umbilical cord, ability to deliver
head but not body
External Cephalic Version
Cesarean Section
May attempt delivery if proven pelvis or
multiple gestation
Transverse Lie
Associated with grand multiparity, preterm
fetus, abnormal uterus, hydramnios,
placenta previa, and contracted pelvis
Risks: prolapsed cord
Management: external cephalic version,
cesarean section
Macrosomic Fetus
Greater than 4000g (8# 8oz) at birth
Most common in male infants, offspring of
large parents, diabetic women, mothers with
a previous macrosomic infant, multiparity
and prolonged gestation
Risks of Macrosomia
Maternal
– CPD
– Dysfunctional labor
– Soft tissue
laceration during
vaginal birth
– Postpartal
hemorrhage
Fetal
– Meconium
aspiration
– Asphyxia
– Shoulder dystocia
– Upper brachial
plexus injury
– Fractured clavicles
Multiple Gestation
Associated with infertility treatments
Spontaneous twins are more common in
African Americans, advanced maternal age,
women who are tall and overweight
Maternal Implications
Urinary tract infections
Preeclampsia
Preterm labor
Placenta previa
Abnormal presentation
Uterine dysfunction
Prolapsed cord
Intrapartum/Postpartum hemorrhage
Fetal/Neonatal Implications
Higher perinatal mortality rate
Intrauterine growth restriction in one or both
babies
Increased incidence of fetal anomalies
Prematurity and associated risks
Abnormal presentation
Cerebral palsy
Long term disabilities
Twin to twin transfusion
Care of Multiple Gestation
Bed rest/Pelvic rest
Weekly-Biweekly NST/BPP after 30-34
weeks
Large bore IV, type and crossmatch
Prep for both vaginal and cesarean delivery
if vaginal birth is attempted
Duplication of everything in the delivery
room
Non Reassuring Fetal Status
Usually caused by cord compression or
uteroplacental insufficiency
If hypoxia persists permanent damage to the
fetus may occur
Most common signs are meconium stained
amniotic fluid and non reassuring fetal heart
tones
Intrauterine Resuscitation
Left lateral position
IV fluid bolus
Right side or knee/chest if left lateral does not
work
Discontinue the oxytocin if applicable
Oxygen at 8-10 L/min via facemask
Vaginal examination
Possible tocolytic
Prepare for emergency delivery
Placental Problems
Abruptio placentae
Placenta previa
Placenta accreta
Vasa previa
Retained placenta
Placenta Previa
Placenta is implanted in the lower uterine segment
Bleeding begins as the uterus contracts and the
cervix dilates
Types
– Complete
– Partial
– Marginal
– Low lying
Risk Factors
Minority women
Previous cesarean section
Multiparity
Advanced maternal age
Previous miscarriage
Previous induced abortion
Cigarette smoking
Male fetus
Expectant Management
Bed rest with bathroom privileges (if not actively
bleeding)
No vaginal exams
Monitoring blood loss, pain and contractions
FHR evaluation
H&H, Rh factor, type and crossmatch
Intravenous fluid with Lactated Ringers
Cesarean birth for profuse or recurrent bleeding
Nursing Measures
Contraction and fetal heart rate evaluation
Intake and output
IV fluid
Maternal vital signs
Chux weight for monitoring of blood loss
Abruptio Placentae
Premature separation of the placenta from
the uterus
Leading cause of perinatal mortality
Types:
–
–
–
–
Marginal
Central
Complete
Grades 1, 2 and 3
Risk Factors
Increased maternal age
Increased parity
Cigarette smoking
Cocaine abuse
Trauma
Maternal hypertension
Previous abruption
Rapid uterine
decompression
PPROM
Uterine malformations
Fibroids
Placental anomalies
Inherited
thrombophilia
Maternal Risks
Hemorrhage
Hemorrhagic shock
DIC
Renal failure
Death
Fetal Risks
Preterm problems
Anemia
Hypoxia
Brain damage
Death
Best survival rate if delivered within 20
minutes of initial separation
Care of Placenta Abruption
Large bore IV
Type and Crossmatch
If separation is severe immediate delivery is
indicated
If separation is mild pregnancy can be
maintained with bed rest if preterm or a
vaginal delivery may be attempted if near
term
Placenta Accreta
When the placenta grows through the uterus
usually through a previous cesarean scar
Placenta previa is also associated with this
Complication is hemorrhage resulting from
being unable to remove the placenta
Hysterectomy may be necessary
Retained Placenta
Occurs when the placenta does not separate
from the uterus within 30 minutes after
delivery
Manual removal is required by the
physician
Surgical curettage may be required if unable
to remove manually
Can result in postpartum hemorrhage
Lacerations
Cervical
Periurethreal
Vaginal
– First degree
– Second degree
– Third degree
– Fourth degree
Prolapsed Umbilical Cord
When the cord precedes the fetal presenting
part it becomes trapped between the
presenting part and the cervix
Compression results in blood flow being
restricted to the infant
Care of Prolapsed Cord
If a cord is discovered upon vaginal exam
the hand must remain in the vagina to
relieve pressure on the cord
Knee/chest position or Trendeleberg may
also help
This is what will save the life of the baby
Patient will be prepared for immediate
delivery via cesarean section
Amniotic Fluid Embolism
Occurs with a tear in the amnion or chorion
in the uterus allowing amniotic fluid to
enter the vascular system
Can also enter via placental abruption,
ruptured uterus or cervical tears
The fluid enters the lung and lodges there
after traveling through the vascular system
Signs/Symptoms
Sudden onset of respiratory distress
Dyspnea
Cyanosis
Hemorrhagic shock
Coma
Death
Hydramnios
More than 2000 mL of amniotic fluid
Associated with major congenital anomalies
–
–
–
–
Malformations affecting the swallowing mechanism
Neurological disorders where the meninges are exposed
Anencephaly
Monozygotic twins due to the twin with increased
blood volume with excessive urination
Maternal disorders
– Rh sensitization
– Multiple gestation pregnancy
Risks of Hydramnios
Maternal
Fetal
– Shortness of breath
– Increased mortality
– Lower extremity
rate due to increased
incidence of
malformations
– Prolapsed cord
– Malpresentation
edema
– Placental abruption
– Dysfunctional labor
– Postpartum
hemorrhage
Oligohydramios
Amount of amniotic fluid is severely
reduced
Associated with:
– Postmaturity
– IUGR
– Placental insufficiency
– Fetal renal malformations
Oligohydramnios Risks
Dysfunctional labor
Fetal adhesions if early in pregnancy
Pulmonary hypoplasia
Cord compression
Meconium stained fluid
Cephalopelvic Disproportion
CPD
Associated with pelvic contractures, fetal
malpresentation and fetal macrosomia
Labor is prolonged and cesarean section is
indicated
Should be suspected when adequate labor
does not result in labor progress
Perinatal Loss
Death of fetus or infant from the time of
conception through 28 days of life
Many causes or the cause may be unknown
Maternal Factors
Postterm pregnancy
Diabetes
Chronic hypertension
Preeclampsia/
eclampsia
Advanced maternal
age
Thrombophilias
Antiphospholipid
syndrome
Uterine rupture
Rh disease
Infection
Fetal Factors
Chromosomal disorders
Birth defects
Anencephaly
Open neural tube defects
Congenital heart defects
Hydrops fetalis
Infection
Complications of multiple gestation
Other Factors
Placenta previa
Placental abruption
Cord accident
Premature rupture of membranes
Unknown factors
Complications
Prolonged retention of the dead fetus can
result in DIC
Infection can result with prolonged
retention resulting in endometritis or sepsis
In the case of twins delivery may need to be
delayed if one is living and one is not
Diagnosis/Treatment
No fetal movement later in pregnancy
Absence of fetal heart tones with Doppler
Confirmed by ultrasound and absence of
heart motion and/or Spalding’s sign
Delivery is the only treatment and must be
precipitated to decrease complications
Delivery depends on gestation and previous
deliveries
Evaluation
Before birth: type and Rh, CBC,
coagulation studies
After birth: careful of inspection of fetus,
placenta and umbilical cord
Placenta to pathology for testing
Autopsy if parents consent
Preparation for Birth
Let the family know what to expect based on
gestation and time the fetus has been dead
Assist through the grief process
Comfort and care for the patient and the family
Keep the patient as comfortable as possible
If term, follow the birth plan set forth by the
patient, preterm follow as much as possible
After Delivery
Prepare the infant for viewing by the family
as much as possible
Prepare the family for what to expect
– What the infant looks like
– He/she will be cold
– Color of the infant
– Any birth defects
After Delivery
Allow the family to hold the infant as long
as they want
Collect locks of hair, foot prints, hand
prints, crib cards, identification bands,
pictures, birth certificate in a remembrance
box for the parents
If they decline the box, keep it for them,
they may want it later
Discharge Care
Teach the patient what to expect mentally and
physically
They will have some of the same postpartum
issues as someone that delivered a live baby like
milk coming in
Refer family to support groups, counselors and
provide written material for them to refer to
Remind them that things like mother’s day,
father’s day and birthday will be difficult in the
future