Transcript COMPLICATIONS OF LABOR AND DELIVERY

Complications
of
Labor and Delivery
Presented by
Jeanie Ward
Dystocia
An abnormal, long, or
difficult labor or delivery
Dysfunctional Labor is related to
Abnormalities of the Critical Factors:
PASSAGEWAY
PSYCHE
Critical
Factors
PASSENGER
POWERS
UTERINE DYSTOCIA
DYSFUNCTIONAL UTERINE CONTRACTIONS
HYPOTONIC UTERINE CONTRACTIONS
UTERINE INERTIA
• Etiology and Pathophysiology:
– Overstretching of the uterus --large baby,
multiple babies, polyhydramnios, multiple
parity
– Bowel or bladder distention preventing
descent
– Excessive use of analgesia
ASSESSMENT
• Signs and Symptoms of HYPOTONIC
UTERINE INERTIA:
– Weak contractions – become mild
– Infrequent (every 10 – 15 minutes +) and
brief,
– Can be easily indented with fingertip
pressure at peak of contraction.
– Prolonged ACTIVE Phase
– Exhaustion of the mother
– Psychological trauma - frustrated
Friedman’s Graph
Hypotonic Uterine Contractions
Normal
Curve
Prolonged active phase
Therapeutic Interventions
– Ambulation
– Nipple Stimulation --release of endogenous
Pitocin
– Enema--warmth of enema may stimulate
contractions
– Amniotomy--artificial rupture of the
membranes
– Augmentation of labor with Pitocin
Amniotomy
• Amniotomy is the artificial rupture of the amniotic
sac with a tool called the amniohook (a long
crochet type hook, with a pricked end) or an
amnicot (a glove with a small pricked end on one
finger).
• One of these will be placed inside the vagina,
where the caregiver will rupture the amniotic sac
or membrane.
AMNIOTOMY
• Advantages of doing this before Pitocin
– Contractions are more similar to those of
spontaneous labor
– Usually no risk of rupture of the uterus
– Does not require as close surveillance
• Disadvantages of an Amniotomy
– Delivery must occur
– Increase danger of prolapse of umbilical cord
– Compression and molding of the fetal head (caput)
Amniotomy
• Nursing Care:
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–
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–
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# 1-Check the fetal heart tones
Assess color, odor, amount
Provide with perineal care
Monitor contractions
Check temperature every 2 hours
Answer
Cervical Ripening
Cervical Ripening
• prostaglandin E2 Medications
– Prepidil gel
– Cervodil
• Prostaglandin E1 Medication
– Cytotec
• Nursing Care
– Monitor maternal vital signs, cervical dilatation and
effacement
– Monitor fetal status for presence of reassuring fetal
heart rate
– Remove medication if hyperstimulation occurs
Hyperstimulation
• Remove the medication
• Turn patient to side-lying position
• Provide oxygen via face mask
• Give Terbutaline
PITOCIN
Augmentation of Labor
• Assess first to make sure CPD is not present,
then start procedure:
– Give 10 units / 1000 cc. fluid and hang as a secondary
infusion, never as primary
• Nursing Care:
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–
–
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Assess contractions--are they increasing but not tetanic
Assess dilation and effacement
Monitor vital signs and FHT’s
Make sure no signs of hyperstimulation before
increasing dose
HYPERTONIC UTERINE
CONTRACTIONS
• Most often occur in first-time mothers,
Primigravidas
• Contractions are ineffectual, erratic,
uncoordinated, and of poor quality that
involve only a portion of the uterus
• Increase in frequency of contractions, but
intensity is decreased, do not bring about
dilation and effacement of the cervix.
Signs and Symptoms
– PAINFUL contractions RT uterine muscle
anoxia, causing constant cramping pain
– Dilation and effacement of the cervix does not
occur.
– Prolonged latent phase. Stay at 2 - 3 cm. don’t
dilate as should
– Fetal distress occurs early– uterine resting
tone is high, decreasing placental perfusion.
– Anxious and discouraged
Friedman’s Graph
Hypertonic Uterine Contractions
Prolonged latent
phase
Relieve pain and promote
normal labor pattern
Treatment of Hypertonic
Uterine Contractions
• Provide with COMFORT MEASURES
Warm shower
Mouth Care
Imagery
Music
Back rub, therapeutic touch
•
•
•
•
Mild sedation
Bedrest or position changes
Hydration
Tocolytics to reduce high uterine tone
Ineffective Maternal Pushing
• Results from:
– Incorrect pushing techniques
– Fear of injury
– Decreased urge to push
– Maternal exhaustion
• Treatment
– Teaching
Complication
of the
Passenger
Fetal Size
• Macrosomia
– Infant weighs more than 8 lb. 13 oz.
– Shoulder dystocia
• McRoberts maneuver
• Suprapubic pressure
Abnormal Presentation and
Positions
• Malpositions:
– Posterior position--usually mom complains of
back pain
• Malpresentation
Brow Face -
Breech -
Transverse -
Problems of Passenger
• Cephalopelvic Disproportion (CPD)
– Large baby or small pelvis
– Usually diagnosed when there is an arrest in
descent
– Station remains the same
• Multiple Fetus
– Twins, triplets, etc.
Treatments for Complications of
the Passenger
– Positioning – hands and knees, lunge to side
– Version -- alteration of fetal position by abdominal
or intrauterine manipulation
– Amnioinfusion - infusion into the uterine cavity
– Forceps -- low forceps or outlet forceps usually
applied after crowning
– Vacuum extraction -- disk shaped cup placed over
vertex of head and vacuum applied.
– Episiotomy - surgical incision to allow more room
– Cesarean Delivery
External Version Procedure
A version is a procedure used to change the
position of the fetal presentation by abdominal
manipulation.
External Version Procedure
• Criteria
– Fetus is not engaged
– A reactive NST
– 36+ weeks gestation
• Contraindications
– A complicated pregnancy
– Multiple pregnancy
– Non-reassuring FHR
• Nursing Care
– Administer terbutaline prior to start
– Monitor maternal and fetal vital sign
– Post – assess for contractions and kick-counts
Episiotomy
Episiotomy
• Factors that predispose:
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–
–
–
Primigravida
Large baby, macrosomia
Posterior position of baby
Use of forceps or vacuum extractor
• Preventive Measures
– Perineal massage
– Side-lying for expulsion
– Gradual expulsion
• Nursing Care
– Provide comfort and patient teaching
– After delivery- apply ice and assess site
Forceps-assisted Delivery
Used to shorten the second stage
of labor and assist the woman’s
pushing efforts.
Forceps-Assisted Delivery
• Risks
– Fetus
• Facial edema or lacerations
• Caput succedaneum or cephalohematoma
– Maternal
• Lacerations of birth canal
• Perineal bleeding, bruising, edema
• Nursing Care
– Preventive measures to decrease need for forceps
– Patient teaching
– After – assessment of newborn and assessment of
woman’s perineum.
Vacuum Extraction
Vacuum Extraction
• Used to shortening the second stage of labor
and delivery of the fetus
• Risk
– Cephalohematoma or caput succedaneum
• Nursing Care
– Keep woman and partner informed during the procedure
– After – assess newborn
CESAREAN DELIVERY
• OPERATIVE PROCEDURE IN WHICH THE FETUS
IS DELIVERED THROUGH AN INCISION IN THE
ABDOMEN
• REMEMBER -- IT IS A BIRTH !
• Mom may feel less than normal, so may need
support
• May have option of a VBAC the next time
VBAC
Vaginal Birth After Cesarean
• A woman may be considered a candidate for a
VBAC if the following guidelines are met:
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With previous C-section, had low transverse incision
Has an adequate pelvis (absence of pelvic dystocia)
A woman who had a previous VBAC
Hospital must be set up to perform an emergency
cesarean within 30 minutes.
Vertical
Low Transverse
Cesarean Birth
• Nursing Care
– Frequent monitoring of woman and fetus
• Complication
– Uterine rupture
Cephalopelvic Disportion (CPD)
• Causes
– Large baby or small pelvis
– Usually diagnosed when there is an arrest in
descent
• Symptoms
– Station remains the same does not descend
• Treatment and Nursing Care
– Usually do a cesarean delivery if cause is pelvis
– Utilize other measures such as forceps, vacuum
extraction, episiotomy.
Explain
Too Slow
Too Fast
Prolonged Labor
Failure to Progress
Definition:
• A labor lasting more than 18 - 24 hours or fails to
make changes in dilation or effacement
• Cervical dilation -- Primigravida 1.2 cm / hr.
Multigravida 1.5 cm / hr
• Descent – 1 cm. / hr in primigravida and 2 cm./ hr.
in multigravida
• Etiology
– CPD - Cephalo Pevlic Disportion
– Malpresentation, malposition
– Labor dysfunction
• Therapeutic Interventions
–
1.
2.
3.
4.
depends on the cause
Provide comfort measures
Conservation of energy
Psychological support
Position changes
PRECIPITIOUS LABOR OR DELIVERY
• Labor that last less than 3 hours
• Unexpected fast delivery
• Etiology
– Lack of resistance of maternal tissue to passage of fetus
– Intense uterine contractions
– Small baby in a favorable position
• Complications/ Risks:
– If the baby delivers too fast, does not allow the cervix to
dilate and efface which leads to cervical lacerations
– Uterine rupture
– Fetal hypoxia and fetal intracranial hemorrhage
Rapid Delivery
Delivery Outside Normal Setting
• Everything is OUT OF CONTROL!
– mom is frightened, angry, feels cheated
• Nursing Care:
– Do NOT leave the mother alone
– Try to make the place clean, (don’t break down table)
– Try to get the mother in control -- Have mom pant to decrease
the urge to push
– Apply gentle pressure to the fetal head as it crowns to prevent
rapid change in pressure in the fetal head which can cause
subdural hemorrhage or dural tears.
– Deliver the baby BETWEEN contractions to control delivery
– Suction or hold baby’s head low and place on mom/s
abdomen, tie off cord
– Allow to breast feed, Document!
Premature Rupture of the Membranes
• Definition:
– Spontaneous rupture of the membranes
• Etiology
– Infections
- Incompetent cervix
– Fetal abnormalities - Sexual Intercourse
• Major risk - ascending intrauterine
infection
• Other risk -- Precipitation of labor
• Treatment and Nursing Care:
– Wait and watch, bedrest, no
intercourse
– Assess time membranes ruptures and if
labor started
– Check temperature frequently
– Describe character of amniotic fluid
– Check WBC
– Provide psychological support
Accelerating Fetal Lung Maturity
• Betamethasone (Celestone) or
dexamethasone(Decadron are given to stimulate
the lungs and accelerate fetal lung maturity
thereby decreasing chance of respiratory distress
syndrome.
• Lasts for about 7 days and need to repeat/
Preterm Labor
• Definition:
– Labor that occurs after 20 weeks but before 37
weeks
• Etiology:
– urinary tract infections
– Premature rupture of membranes
• Goal -- STOP THE LABOR ! suppress uterine
activity
Therapeutic Interventions
Drug Therapy
Tocolytics
• Uses: Stop or arrest labor
• Criteria for use, don’t give if:
– Patient is in Active labor, cervix has dilated to
4 cm. or more
– Presence of Severe Pre-eclampsia
– Fetal complications / Fetal demise
– Hemorrhage is present
– Ruptured membranes
TOCOLYTIC MEDICATIONS
β-adrenergic agonist
• Examples:
– Yutopar (ritodrine) or Brethine (terbutaline sulfate)
• SIDE EFFECTS or WARNING SIGNS:
– Palpitations
– Tachycardia - pulse ~120
– Tremors, nervousness, restlessness
– Headache, severe dizziness
– Hyperglycemia
• TOXIC EFFECTS - PULMONARY EDEMA
• rales, crackles, dyspnea noted on routine
nursing chest assessment every shift
Tocolytic Drugs
• Nursing Care:
– Stop the medication
– Start oxygen
– Give ANTIDOTE: INDERAL
Tocolytic Medications
Magnesium Sulfate
• Decreases frequency and intensity of uterine
contractions
• Given via IV infusion pump
– Loading dose 4-6 g in 100 ml given over ~20 minutes
– Maintenance dose – 1-4 g per hour.
• Side effects
– Lethargy and weakness
– Sweating, flushing,
– N/V, headache, slurred speech
• Toxic effects
– Absences of reflexes
– Respiratory depression
Tocolytic Medications
Calcium Channel Blocker
nifedipine
• Decreases smooth muscle contraction by blocking
the slow calcium channels at cell surface.
• Administration
– Orally or sublingually
• Side Effects
– Hypotension, tachycardia
– Facial flushing
– Headache
Tocolytic Medications
prostaglandin synthesis inhibitor
indomethacin (Indocin)
• Action
– Inhibits prostaglandin synthesis thus reducing uterine
contractions. (Prostaglandins stimulate uterine
contractions)
– Used for pregnancies <32 weeks gestation and not
given for more than 72 hours.
– Not a widely used medication to treat preterm labor.
Self Care Measures
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Rest
Drink plenty of fluids – 2-3 quarts /day
Empty bladder every 2-3 hours when awake
Avoid lifting heavy objects
Avoid overexertion
Modify sexual activity
Preterm labor
• NURSING CARE:
– Teach how to take medication -- on time
– Teach patient to check pulse, call Dr. if > 120 –
140 (dehydration increases contractions)
– Teach to assess fetal movement daily, kick
counts
– Drink 8-10 glasses of water per day
– Monitor uterine activity -- Home monitoring -call dr. if has contractions
– Decrease activity
– Lie on side
– Keep bladder empty
Accelerating Fetal Lung
Maturity
• Betamethasone / Celestone -- provides
stressor to the lungs of the fetus to
stimulate production of surfactant
• Effective if have 24 hours prior to delivery
Prolapse of Cord
Prolapse of the Umbilical Cord
Definition:
• Prolapse of the umbilical cord thorough the
cervical canal along side of the presenting part
Etiology/ Risk Factor:
• Occurs anytime the inlet is not occluded. Fetus
is not well engaged
• GOAL:
– RELIEVE THE PRESSURE ON THE CORD
– SUPPORT MOTHER AND THE FAMILY
Prolapse of the Cord
• NURSING CARE / Therapeutic Interventions:
#1 – Get the Pressure off the Cord
place in trendelenberg or knee-chest position
OR
elevate part with sterile gloved hand
Amnioinfusion
Warmed, sterile Normal Saline or RL is introduced
into the uterus through an intrauterine pressure
catheter (IUPC)
Amnioinfusion
• Used to treat:
– Oligohydramnios
– Meconium-stained amniotic fluid
– Cord compression and variable decelerations
• Nursing Care
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Assess maternal and fetal vital signs
Assess contractions
Provide comfort measures
Measure intake and output of the fluid
Nursing Care for
Prolapse of Umbilical Cord
– Palpate FHT’s, NEVER ATTEMPT TO
REPLACE CORD!
– Give O2 per mask at 10 Liters
– Cover exposed cord with sterile wet gauze
– Stay with the patient and offer support
Amniotic Fluid Embolism
• Escape of amniotic fluid into the maternal
circulation
– usually enters maternal circulation
through open sinus at placental site
• Usually fatal to the Mother
– amniotic fluid contains debris, lanugo,
vernix, meconium, etc.
Amniotic Fluid Embolism
• Signs and Symptoms:
– dyspnea
– chest pain
– cyanosis
– shock
• Therapeutic Interventions:
– Deliver the baby
– Provide cardiovascular and respiratory
support to Mom
Ruptured Uterus
• Spontaneous or traumatic rupture of the uterus
• Etiology:
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–
–
–
Rupture of a previous C-birth scar
Prolonged labor
Injudicious use of Pitocin -- overstimulation
Excessive manual pressure applied to the fundus during
delivery
• Signs and Symptoms:
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Sudden sharp abdominal pain, abdominal tenderness
Cessation of contractions
Absence of fetal heart tones
Shock
• Therapeutic Interventions:
– Deliver the baby ! / Cesarean Delivery
The stimulation of uterine contractions
before the spontaneous onset of labor, for
the purpose of accomplishing birth
Labor Readiness
• Fetal Maturity
• Cervical Readiness with utilization of the
PreLabor Status Evaluation Scoring System/
Bishop’s score
– Assesses cervical dilatation, effacement, consistency,
position, and fetal station.
– A score of 8-9 is favorable for induction
Cervix
Score
Score
Score
Score
0
1
2
3
Posterior
Midposition
Anterior
---
Consistency
Firm
Medium
Soft
---
Effacement (%)
0-30
40-50
60-70
>80
closed
1-2
3-4
>5
Position
Dilation (cm)
Methods of Inducing Labor
• Stripping the Membranes
– With a gloved finger, the amniotic membranes lying
against the lower uterine segment are separated. This
causes release of prostaglandins that stimulate uterine
contractions
• Pitocin Infusion
– The goal is to have contractions occurring every 2
minutes of good intensity with relaxation between.
– Used for induction and augmentation.
Other Methods of Induction
– Ambulation
– Nipple Stimulation --release of endogenous
Pitocin
– Enema--warmth of enema may stimulate
contractions
– Herbs
– Insertion of balloon catheter
Foley catheter with internal stylet is inserting into the os
of the cervix and the balloon is inflated with
sterile saline (~30 ml.)
Mechanical stimulation induces labor
The End
Polyhydramnios and oligohydramnios
• Polyhydramnios – excessive amniotic fluid usually
> 2000 ml.
– Associated with fetal GI anomalies and maternal diabetes
– Treatment – watch and do nothing unless becomes short
of breath and in pain – then do an amniocentesis
• Oligohydramnios – scanty amniotic fluid usually
<500 ml.
– Etiology unknown
– Risks – fetal adhesions and fetal malformations
– Treatment - amnioinfusion