Transcript Chapter 15

Chapter 14
Complications
of Labor and Birth
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
1
Preterm Labor
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2
Objectives
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Define key terms listed.
Discuss four factors associated with preterm
labor.
Describe two major nursing assessments of a
woman in preterm labor.
Explain why tocolytic agents are used in
preterm labor.
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3
Objectives (cont.)


Interpret the term premature rupture of
membranes.
Identify two complications of premature
rupture of membranes.
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Preterm Labor
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Onset of labor between 20 and 37 weeks
gestation
Occurs in about 12% of pregnancies
Accounts for most perinatal deaths not a
result of congenital anomalies
One of most common factors in preterm birth
followed by premature rupture of membranes
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Criteria for Preterm Labor
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Gestation between 20 to 37 weeks
Later preterm is 34 to 36 weeks gestation
Documented uterine contractions every 5 to
10 minutes
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Lasting for at least 30 seconds
Persisting more than 1 hour
Cervical dilation more than 2.5 cm and 75%
effaced
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Associated Factors
for Preterm Labor
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Poor or no prenatal care
Infections, including periodontal
Nutritional status
Sociodemographics
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Associated Factors
for Preterm Labor (cont.)
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Followed by preterm birth
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Maternal anemia
Urinary tract infection
Smoking
Alcohol, drug use
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Signs and Symptoms
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Uterine, menstrual-like cramping
Abdominal cramping
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With or without nausea, vomiting, diarrhea
Any vaginal bleeding
Change in vaginal discharge
Vaginal or pelvic pressure
Low back pain
Thigh pain
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Intermittent or persistent
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Assessment and Management
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Assessment
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Vaginal discharge;
check for presence
of fibronectin
Infection (bacterial or
fungal)
Uterine activity
Fetal heart rate
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Management
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Treat infections
Restrict activity;
lateral position
Ensure hydration
Tocolytic drugs
• Don’t use if woman
actively bleeding
• Usually not effective if
dilated more than 5
cm
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Stopping Preterm Labor
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Focus is on stopping contractions before
cervix dilates beyond 3 cm
Fetal surveillance includes monitoring heart
rate, BPP, NST, and LS ratio to assess lung
maturity
Tocolytic drugs should not be used if
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Woman is hemorrhaging—bleeding will increase
Fetal distress is noted
Tocolytic drugs are not effective if cervix
dilated 5 cm or more
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11
Promotion of Fetal Lung Maturity
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Goal of tocolytic therapy until steroids can
hasten lung maturity
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Respiratory distress (RDS) can be reduced if
steroids are given to mother 24 to 48 hours before
birth in fetus less than 34 weeks gestation
After delivery, infant is treated with
prophylactic surfactant therapy to reduce risk
of developing RDS
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Nursing Care Related
to Pharmacologic Therapy
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Accurate I&O
Monitor breath sounds, vital signs, and
mental status
If woman complains of chest pain or
shortness of breath, stop tocolytics
Assess woman for side effects from the
various pharmacologic agents
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13
Premature Rupture of
Membranes (PROM)
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Spontaneous rupture of amniotic sac more
than 1 hour before onset of true labor
(PROM)
If rupture occurs before 37 weeks gestation, it
is called preterm premature rupture of
membranes (PPROM)
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Complications of PROM
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Infection for mother and fetus
Compression of umbilical cord
Prolapse of umbilical cord
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Management
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Confirming drainage from vagina is amniotic
fluid
Bed rest
Hydration
Sedation
Antibiotics
Reassurance
Augmentation
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16
Audience Response System
Question 1
Respiratory distress (RDS) in an infant born at
less than 34 weeks’ gestation can be reduced if
steroids are given to the:
A. Mother 24 to 48 hours before birth in fetus
B. Infant with 24 to 48 hours after birth
C. Mother within 2 to 4 hours before birth
D. Infant 2 to 4 hours after birth
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The 4 Ps of Labor
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Objectives
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Differentiate between hypotonic and
hypertonic uterine dysfunction.
Name and describe the three different types
of breech presentation.
Explain the term cephalopelvic disproportion
(CPD), and discuss the nursing management
of CPD.
List two potential complications of a breech
birth.
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Objectives (cont.)
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Define and identify three common methods
used to induce labor.
Explain why an episiotomy is performed, and
name two basic types of episiotomies.
Describe three types of lacerations that can
occur during the birth process.
List two indications for using forceps to
deliver the fetus.
Describe vacuum extraction.
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Dystocia
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Known as dysfunctional labor; difficult or
abnormal labor
Primarily results from
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Powers
 Passageway (pelvis)
 Passenger
 Psyche
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Powers
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Abnormal uterine contractions
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Hypotonic dysfunction
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Prevent normal progress of dilation, effacement,
and fetal descent
Contractions weaken, not strong enough to dilate
cervix beyond 4 cm
Hypertonic uterine dysfunction
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Contractions of poor quality, pain is out of
proportion to intensity, dilation and effacement
affected
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Passageway
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Abnormal pelvic size or shape
May be a result of
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Congenital malformation
Rickets
Maternal malnutrition
Tumors
Previous pelvic fractures
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Passenger
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Cephalopelvic disproportion (CPD)
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Abnormal fetal presentation
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Presenting part too large for maternal pelvis
Fetus not in vertex position
Breech, face-brow, persistent occiput posterior
External version
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Can help reduce the need for cesarean
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Psyche
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Epinephrine is released in response to stress
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Inhibits contractions and diverts blood from uterus
Examples
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Perceived fears of pain
Nonsupport
Embarrassment
Violation of religious rituals
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Induction of Labor
and Augmentation
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Induction
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Measures taken to initiate uterine contractions
before they spontaneously begin
Augmentation
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Use of an oxytocic drug after spontaneous but
ineffective labor has begun
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Reasons for Induction
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Maternal indications
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Infection (chorioamnionitis)
PROM
Worsening medical disorders (e.g., gestational
hypertension)
Fetal indications
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Intrauterine growth restriction
Postterm newborn
Fetal demise
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Methods of Induction
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CAM therapy
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Primrose oil, black haw, black cohosh, red
raspberry leaves
Sexual intercourse
Acupuncture and TENS
Cervical ripening
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Evaluated using Bishop’s score
6 or higher predicts higher success rate
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Methods of Induction:
Nonpharmacologic
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Stripping of membranes
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Amniotomy
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Artificial rupture of membranes
Mechanical dilators
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Digital separation of amniotic membranes
Inserted into cervix to gradually increase dilation
Can be painful, replaced by
Hygroscopic dilators
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Laminaria (seaweed)
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Methods of Induction:
Pharmacologic
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Prostaglandin (PGE2) gel
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Nausea, vomiting, diarrhea, fever,
hyperstimulation of uterus
Misoprostol (Cytotec)

Has special guidelines that must be followed
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Oxytocin Induction
and Augmentation
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Helps induce the labor process or augment
labor that is progressing slowly due to
ineffective uterine contractions
Has antidiuretic effect
Common side effects include
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Uterine hyperstimulation
Reduced fetal oxygenation
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Oxytocin and Nursing
Assessment
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Uterine activity
Cervical dilation
Maternal-fetal response
Intake and output
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To assess for water intoxication
Discontinue administration immediately if
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Uterine hyperstimulation
Nonreassuring fetal heart rate
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Episiotomy
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Surgical incision
made into perineum
to permit easier
passage of fetus
Shortens second
stage of labor
Relieves compression
of fetal head
Facilitates breech and
forceps birth
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Assisted Vaginal Delivery
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Forceps-Assisted Birth
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Criteria
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Membranes ruptured
 Cervix fully dilated
 Fetal head below
ischial spines or on
perineum
 Bladder empty
 Analgesia adequate
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Vacuum Extraction
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Application of a cup
to fetal head
Withdrawal of air
from cap
Traction applied
during uterine
contractions
Fetal head then
delivers
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Contraindications to Induction
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Induction of labor is contraindicated if the
mother has

Active genital herpes
 Cephalopelvic disproportion
 Umbilical cord prolapse
 Placenta previa
 Vertical incision of the uterus from a previous Csection or other form of surgery
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Audience Response System
Question 2
A hygroscopic dilator is used to:
A. Break the bag of water
B. Access the uterus
C. Induce labor
D. Stimulate the uterus
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Uterine Complications
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Objectives
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Define precipitate labor, and describe two
nursing actions that should be taken to
safeguard the baby.
Review the most common cause of rupture of
the uterus during labor.
Describe umbilical cord prolapse, and state
two associated potential complications.
List three potential complications of multifetal
pregnancy.
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Objectives (cont.)
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Discuss five indications for a cesarean birth.
Describe the preoperative and postoperative
care of a woman who is undergoing a
cesarean birth.
Discuss the rationale for vaginal birth after a
prior cesarean birth.
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Postterm Labor and Birth
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Birth beyond 42 weeks gestation
Risks to mother
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Dysfunctional contractions
Vaginal canal lacerations
Risks to fetus
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Birth trauma
CPD
Hypoxia
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Precipitate Labor
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Labor completed in less than 3 hours from
time of first true labor to birth of fetus
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Can cause fetal hypoxia
Intervillous blood flow may be impaired because
uterus cannot relax enough
Cervical, vaginal, or perineal lacerations can occur
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Uterine Rupture
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Rare
Occurs most often during labor and delivery
Associated with previous cesarean
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Rupture occurs at site of previous surgical scar
Aggressive or poorly supervised induction of
labor
Fetopelvic disproportion
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Hydramnios
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Excessive amount of amniotic fluid, greater
than 2 L
Congenital anomalies, especially of fetal GI
tract
Uterus overdistends
Removal of excess amniotic fluid may cause
abruptio placentae or prolapsed cord
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Oligohydramnios
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Decreased amount of amniotic fluid
Associated with
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Fetal renal anomalies
Intrauterine growth restriction
Fetus at risk for impaired musculoskeletal
development
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Prolapse of the Umbilical Cord
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Cord precedes fetal presenting part
Contributing factors
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ROM before fetal head engaged
Small fetus
Breech presentation
Transverse lie
Hydramnios
Unusually long cord
Multifetal pregnancy
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Nursing Interventions in
Prolapsed Cord
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Place woman’s hips higher than head by
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Knee-chest position
Trendelenburg position
Side-lying position with hips elevated on pillows
With sterile gloved hand, push fetal
presenting part away from cord
Start oxygen 8 to 10 L/min by mask
Closely monitor FHR by EFM
Prepare for rapid delivery
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Amnioinfusion
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Normal saline or lactated Ringer’s solution
instilled into amniotic cavity
Corrects oligohydramnios
Reduces thickly stained meconium
Minimizes cord compression
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49
Multifetal Pregnancy
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Two or more fetuses in utero
Preterm labor can occur due to overdistended uterus
Increased risk of anemia, hypertension, and
hemorrhage
Twin-to-twin transfusion syndrome
Death of one twin in utero while other
survives; increases risk of DIC in mother
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Cesarean Birth


Birth accomplished through abdominal and
uterine incision
Basic purpose to preserve life or health of
mother and fetus
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Indications
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Previous cesarean birth
Failed trial of labor (failure to progress)
Fetal distress
Uncontrolled bleeding
Fetopelvic disproportion or malpresentation
Prolapsed cord
Active herpes simplex viral infection
Postmaturity
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Surgical Techniques

Skin incisions
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Transverse (Pfannenstiel’s)
• Lowest part of abdomen
• Does not allow for extension of incision
Vertical
• Between naval and symphysis pubis
• Quicker and preferred in fetal distress
Uterine incisions


Upper or lower segment
Upper has higher risk of rupture with future
pregnancy
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Complications and Risks

Maternal

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Aspiration
Pulmonary embolism
Hemorrhage
Urinary tract infection
Bowel or bladder
injury
Infection
Thrombophlebitis
Anesthesia
Fetal



Preterm (if
gestational age not
correctly calculated)
Fetal injuries
Respiratory problems
• Delayed absorption of
lung fluids
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Preparation for Cesarean Birth

Psychological preparation

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If prepared correctly, woman appears to cope with
recovery better than those who have not
Emergent or unplanned

Woman approaches procedure exhausted and
possibly discouraged
 Time for explanation is often limited
 May not have been appropriately prepared
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Nursing Care:
Preoperative Care
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NPO to reduce risk of aspiration
IV access started and confirmed
Witness informed consent
Cleanse abdomen; clip hair if the hair may
interfere with closing and suturing of wound
Indwelling Foley catheter is placed
Administer medications as ordered
Review laboratory results
Provide teaching
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Newborn Care

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Pediatrician and newborn nursery nurse
typically present in delivery room
Heated crib and resuscitation equipment
Infant placed in radiant warmer; skin
temperature probe applied
Apgar scoring
Identification banding
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Postoperative Care

Observe
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Firmness of uterus
Bleeding from vagina
Abdominal incision
Vital signs per protocol
IV oxytocin
Facilitate bonding and attachment of parents
and newborn
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Trial of Labor After Cesarean
(TOLAC)

Contraindications

Dystocia
 Increased maternal age
 Gestational age >40 weeks
 Maternal obesity
 Preeclampsia
 Macrosomia
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Vaginal Birth After Cesarean
(VBAC)


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
Intrapartum care essentially same as for any
woman in labor
Close observation of fetal status and uterine
contractions
Use of cervical ripening not recommended
Augmentation with oxytocin can be done with
close monitoring
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ACOG Guidelines
for Vaginal Birth After Cesarean





One previous cesarean birth with transverse
uterine incision
Documented adequacy of pelvis
Availability of facilities to perform cesarean
within 30 minutes
Electronic fetal monitoring
IV access
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Audience Response System
Question 3
Placing the woman’s hips higher than her head
using knee-chest position, Trendelenburg
position, or side-lying position with hips
elevated on pillows is done in which situation?
A. Amnioinfusion
B. Breech presentation
C. Prolapsed umbilical cord
D. Precipitate delivery
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Review Key Points
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