Transcript Chapter 22: Processes and Stages of Labor and Birth

Complication o Labor
Psychologic Disorders
Alterations in thinking, mood or
behavior
Keep her well oriented and promote
optimal functioning in labor. Focus on
maintaining safe environment and
ensuring fetal and maternal well-being
Dystocia r/t dysfunctional
contractions
Accounts for ~ 50% C/S for primips; <5%
C/S for multips
Hypertonic: in 1st phase- poor quality U/Cs,
become more frequent, but ineffective and
changing dilatation or effacement
prolonged latent phase
Tx: sedation, oxytocin, amniotomy
Hypotonic: irreg, low amplitude
protracted labor and arrest of dilatation
Tx: oxytocin, amniotomy
Active Management of Labor
Standardized criteria for diagnosis of labor
Standardized method of labor management
One-to-one nursing care in labor
Prenatal education to teach re: this protocol
Method:
Amniotomy right away
VE frequently
If change not as expected, oxytocin
Precipitous Labor and Birth
From beginning of regular
contractions to delivery is 3 hours or
less
Risks:
Abruption
Cervical and perineal lacerations
Fetal head trauma
Women with history may be
scheduled for induction
Post-term Pregnancy
> 42 completed weeks
Cause of true post-term is unknown; often
incorrect dates
Maternal Risks:
Large baby and associations
Psychologic ills
Fetal-Neonatal Risks:
Placental changes  insufficiencies
Oligohydramnios
macrosomia birth trauma, glucose maintenance problems
Meconmium stained fluid (aspiration)
As pregnancy approached term, fetal well-being studies
done
Fetal Malposition
OP position:
Fetus must rotate 135° or occasionally
born in OP position
If born OP, increased risk of 3rd or 4th
degree laceration, broken symphysis
May use forceps or manual rotation
Positioning: knee chest, pelvic rocking
Fetal Malpresentation
Brow
Usually C/S recommended
Perinatal morbidity and mortality:
Trauma: cerebral and neck compression; damage to
trachea and larynx
Tx: pelvimetry, oxytocin?, C/S
Face
Perinatal morbidity and mortality:
Risk of prolonged labor, fetal edema, swelling of neck
and internal structures, petechiae, ecchymosis
Tx: C/S in no progress
Fetal Malpresentation
Breech
Most common malpresentation
Frank breech most common
Risk of cord prolapse; fetal anomolies 3x
higher
If vag del: head trauma, fetal entrapment
Tx: external version (50-60% success), if
vag del: epidural, double set-up
Fetal Malpresentation
Shoulder
Version may be attempted
C/S
Compound presentation
Macrosomia
>4500 g
Obese 3-4x more likely to have
macrosomic baby
↑risk of perineal lacerations, infection
Most significant problem is shoulder dystocia
OB emergency permanent injury of brachial plexus,
fx clavicle, asphyxia, neurologic damage
Tx:
Assessment of adequacy of pelvis
Suprapubic pressure
Intentional breaking of clavicle
?C/S
Multiple Gestation
Mother at risk for:
Hypertension or preeclampsia
Anemia
Hydramnios
PPROM, IUGR, incompetent cx
Malpresentation
More physical discomforts
Multiple Gestation
Tx:
U/S to diagnose amnion/chorion, follow
growth, observe for twin-twin transfusion
Frequent office visits to monitor for
problems
Likely to deliver by C/S
Abruptio Placentae
Premature separation of normally
implanted placenta from the uterine wall
Very high mortality
Cause unknown but r/t
Maternal hypertension
Maternal trauma
Cigarettes, cocaine
Short umbilical cord, high parity
More common in Caucasian and African
American than Asian or Latin American
Abruptio Placentae
Abruptio Placentae
Abruptio Placentae
http://video.about.com/pregnancy/Pla
centa-Abruptio.htm
Abruptio Placentae
Classification
O=asymptomatic, diagnosed after birth
I=mild, most common
II=mod, both mom and baby show signs
of distress
III=severe, maternal shock and fetal
death likely
Abruptio Placentae
Types
Marginal-blood passes between fetal
membranes and uterine wall and
escapes vaginally; separation at
periphery of placenta
Central-separates centrally, blood
trapped between placenta and uterine
wall. No overt bleeding
Complete-massive vaginal bleeding in
presence of almost total separation
Abruptio
Placentae
Abruptio Placentae
Blood invades myometrial tissue 
pain and uterine irritability.
May necessitate hysterectomy after
delivery secondary to inability to
uterus to contract.
May lead to coagulation defects
Abruptio Placentae
Maternal Risks
Blood coagulation problems
Shock
Renal failure (r/t hemorrhage)
Possible hysterectomy
Fetal-Neonatal Risks
If separation ~50%  100% demise
Depending upon separation, time before
delivery, maturity of baby  neurologic
damage
Abruptio Placentae
Tx
Continuous EFM (if baby alive)
Develop plan for birth
Maintain CV status/tx hypovolemic
shock
Follow blood coag studies/have blood
factors available
Placenta Previa
Improperly implanted in lower uterine
segment
Types
Low lying: close proximity to os, but
doesn’t reach it
Marginal: edge of placenta at margin of
the os
Partial: internal os is partially covered by
placenta
Total: internal os completely covered
Placenta Previa
Placenta Previa
Placenta Previa
Placenta
Previa
Placenta Previa
Cause unknown, but associated with
Multiparity
Increased age
Defective development of blood vessels
in decidua
Defective implantation of the placenta
Prior C/S
Smoking
Large placenta
Placenta Previa
Tx
Continuous EFM
Differential diagnosis
☺No vag exam until previa r/o (U/S,
other assessments)
Care depends on amt bleeding,
gestational age, assessment of fetus
Other Placental Problems
Note re: infarcts and calcifications
As placenta matures  calcifications
and infarcts
Calcification more often r/t age and diabetes
Infarcts more often r/t severe preeclampsia
and smoking
Prolapsed Cord
Umbilical cord precedes presenting
part
May be visible or occult
More common with
Abnormal lie
Low birth weight
> previous births
Amniotomy
Long cord
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
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 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 (>3000mL) may experience severe
edema, hypotension (from vena cava
compression) and pain
Tx
Supportive
Corrective: may do amniocentesis, Indocin (to
↓ fetal urine output)
Amniotic Fluid-Related Complications
Oligohydramnios
<500mL fluid or largest pocket of
fluid on U/S is <5cm
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
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 families
Listen
Avoid inappropriate consolations
Give accurate info
Obtain mementos
Allow opportunity to see and hold
Provide information re: burial options
Provide support information
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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PROM
Signs 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
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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PROM
Nursing 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
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
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
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+
posterior
medial
Anterior
Consistency of
cervix
Firm
Medium
soft
Station of
presenting
part
-2
-1/0
+1/+2
Position of
cervix
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
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
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 > blood loss, longer
healing time and more discomfort
Tx
Pain relief measures
Ice
Inspect!
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
Operative Assisted Deliveries
Vacuum Extractor
Longer duration of suction, more likely
scalp injury
Maternal complications
Perineal trauma
Edema
Genital tract and anal sphincter probs (< than with forceps)
Neonatal complications
Scalp lacerations
Bruising/subdural hematoma
Cephalohematoma
Jaundice
Fx clavicle
Retinal hemorrhage
death
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 > than vag
delivery
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
Cesarean Birth
Cesarean Birth
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
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
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
Cesarean Birth
Prep for C/S (time dependent)
Permits
IV
Foley
Shave
NPO
Oral/IV antacids, H2 inhibitors
Teaching
Immediate PP care
Freq vs (q 5-10 min)
Check dressing
Lochia and uterus
Lungs
I&O
Anesthetic level
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
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.