Complications of Labor and Birth
Complications of Labor and Birth NSG 330
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This 13 page Class Notes was uploaded by Brieanna Phipps on Monday March 14, 2016. The Class Notes belongs to NSG 330 at University of North Carolina - Wilmington taught by Dr. Goff in Spring 2016. Since its upload, it has received 20 views. For similar materials see Maternal Infant in Nursing and Health Sciences at University of North Carolina - Wilmington.
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Date Created: 03/14/16
Labor and Birth Complications Dystocia o A difficult labor, a labor that is made longer or more painful by problems associated the five P's: Powers Passage Passenger Position Psychological Responses Powers o Primary- mom does not influence, she cannot control Leads to cervical change o Secondary- mom does control (while pushing) Probs w/ primary powers o Hypotonic – lot of contractions but they are low amplitude, just kinda crampy o Infrequent- strong but not occurring fast enough o I&H- not occurring strong or fast enough o Tachy- too many, can cause hypoxia o Hypertonic uterine dysfunction o Occurs during latent phase o Least common o Constant muscle tension, but no cervical change o noT effective in causing cervical dilation o Frequent low contractions o Extremely painful o Most often in anxious primigravida o Highest rate in women age 40 or older o Lowest rate in women ages 20 to 24 o Happens more in older first time moms o Risks: Maternal exhaustion, dehydration due to prolonged labor Fetal hypoxia > distress Fetal distress d/t decreased resting time between contractions o Medical management: 4 to 6 hour rest, fluids, sedatives No oxytocin Mom will likely wake up in labor after rest Hypotonic Uterine Dysfunction o Active phase dysfunction o Uterine contractions decrease in strength and frequency after the onset of true labor o Weak irregular contractions during the active phase of labor o Irregular, low amplitude contractions o Less than 1 cm dilatation per hour o Or No cervical dilatation in 2 hours o (Arrest of progress) o Etiology: Bladder distension Sedation CPD (baby too big for moms pelvis) o Risks: Infection PP hemorrhage due to uterine atony Maternal exhaustion Dehydration Mom is contracting but not making any progress. Labor is slow so mom gets tired, membranes are ruptured so risk of infection Hemorrhage due to uterine muscles being tired o Medical management: R/O CPD or presentation that would prevent a vaginal birth. (R/O = rule out) If CPD R/O, amniotomy and pitocin augmentation are used. Active Management of Labor (AMOL) Protocols o Labor is managed with amniotomy, timed cervical examinations, and Pitocin augmentation if adequate progress is not made. o Decreases risk of : Dysfunctional labor patterns Length of labor Febrile conditions o Stresses low nurse : patient ratio o Once membranes are ruptured want to check cervix as infrequently as possible to dec. risk of infection Nursing Care o Nursing Diagnoses: Pain Anxiety Risk for ineffective coping Knowledge deficit, fluid volume deficits o Frequent position changes: Side-lying, high-Fowler's, rocking chair, sitting up, and walking Moving helps move baby down into the pelvis o Comfort measures such as shower, whirlpool o Quiet environment, music, touch, massage, effleurage, relaxation exercises o Encourage to void every 2 hours o Mom wants to keep bladder empty – q2hr o Effleurage = mom rubbing belly Precipitous Labor o Extremely rapid labor and birth within 3 hrs o Maternal risks: Lacerations (perineal, vaginal or cervical) Increased risk of PP hemorrhage Placental abruption o Fetal risks: Meconium-stained amniotic fluid Low Apgar scores Intracranial trauma resulting from rapid birth o Precipitous labor is more painful o Baby can have intracranial hemorrhaging and even possible seizures Dystocia related to Passage o CPD (Cephalopelvic Disproportion) TFTF!!! (too fat to fit) Any problems with the materanl pelvis can cause CPD Leads to extreme molding of the fetal head Gynecoid is the best shape for maternal pelvis o Molding- bones adjust to let babies head fit through canal, goes away in a couple of days Dystocia related to Passenger- o If baby is in occiput posterior- Risks: Intense back pain; Prolonged labor, especially second stage 3rd and 4th degree lacerations Very painful labor – provide sacral pressure, change positions Nursing management- Change maternal position to side-lying or knee-chest with counterpressure on sacral area Pelvic rock o If baby is in Breech- Risks: Prolapsed cord (medical emergency) Head trauma during vaginal birth Slow descent Sometimes head gets stuck Establish an IV Tocolytic (Terbutaline) Monitor maternal VS Monitor FHR every 1-2 minutes during procedure and following procedure for 1-2 hrs External version before 37 weeks Prior preparation NPO Ultrasound NST or Fetal monitoring for 10 to 20 minutes Give tributiline and mineral oil to prepare her Would want to do a non stress test on baby to make sure he is happy aka alive Types of breech Frank – hips are flexed Complete- knees are bent Incomplete – knee or foot is extended o Abnormal presentations- If brow/face present first- risks include o CPD, prolonged labor, infection, trauma Uncommon C/S if persists If baby does not flex head enough brow or face may be presenting part = need a c section Twin pregnancies- o Dizygotic = two different eggs (fraternal) o Monozygotic = one egg divides (identical) o Complications- PIH (pregnancy induced hypertension) Hydramnios (too much fluid) Placenta previa (placenta is close to presenting part of cervix Preterm labor Anemia (babies drain mom of nutrients they need Postpartal bleeding- uterus is stretched, does not want to contract after delivery Congenital anomalies Twin-to-twin transfusion (monozygotic twins) one twin takes nutrients from other, dec in size of other baby o Psychosocial nursing diagnoses: Parental role conflict related to recent discovery of multiple pregnancy Fear concerning her own and the babies’ health related to risks of multiple pregnancy Macrosomia- o Weight of greater than 4000 g o Associated with: Post-term pregancy Maternal obesity Maternal diabetes History of large infant or previous shoulder dystocia o Maternal Risks: CPD Prolonged labor Uterine atony o Fetal Risks: Shoulder dystocia! Birth trauma Shoulder Dystocia- o Can cause broken clavicle or nerve damage o Apply downward suprapubic pressure Applying fundal pressure can rupture uterus Umbilical cord Variations- o Prolapsed Umbilical Cord: cord precedes fetal presenting part and is compressed when trapped between presenting part and maternal pelvis. May extend down the vagina or lie beside or just ahead of the fetal head (occult cord prolapse) Prolapsed chord will present with fetal bradycardia, can feel it pulsating with vaginal exam Contributing factors: when pelvic inlet is not completely filled by the presenting part and membranes are ruptured (low birth weight, footling breech, shoulder presentation, multiple gestation, long umbilical cord) Fetal risks: Distress, hypoxia Prevention: Labor patients with ROM should remain on bed-rest until engagement Don’t break water when the baby’s head is still high Management: Insert gloved hand into vagina and lift fetal part off cord until physician arrives/baby is delivered Oxygen Knee-chest or trendelenburg position. Move to the OR! o Short Cords- Rarely cause complications o Long Cords- may twist and tangle around fetus, causing transient variable decelerations o Absence of umbilical vessel: May be associated with other fetal anomalies Dystocia related to Position- o Want mom up and moving around as much as possible, let gravity help us o Use gravity when possible o May impede or promote labor progress o Change position frequently and in relation to position of fetus Dystocia related to psychological responses- o Stress, anxiety, and fear affect the labor process o Anxiety and fear may cause increased pain and catecholamine release, leading to physical distress, myometrial dysfunction, and dysfunctional labor o Anxiety will prolong labor o Exhaustion and stress lead to altered coping o Women in abusive relationships may exhibit anxiety or be very passive o Nursing support during labor: o Establish rapport (calm, caring, confident, nonjudgmental approach) o Information o Comfort measures o Touch o Therapeutic communication Labor and birth complications part 2 Amniotic fluid embolism- o Bolus of amniotic fluid enters maternal circulation and then enters maternal lungs o Rare complication Hydramnios/polyhydramnios- o Greater than 2000 cc amniotic fluid o Fundal height increases out of proportion to gestational age o Occurs with GI abnormalities o May increase the risk of prolapsed cord and fetal malpresentation o Fundal height is about the same as gestational age + or – 2 weeks o Amniotic fluid comes from babies kidneys so if too much baby is peeing but not swallowing so a GI abnormality more than likely o If too little GU abnormality b/c baby is not peeing it out o If severe enough to cause maternal dyspnea and pain, may be treated by amniocentesis or prostaglandin synthetase inhibitors (Indomethacin) o Indomethacin suppresses fetal amniotic production Indomethacin (Indocin) o Nonsteroidal anti-inflammatory drug (NSAID) o A side effect is oligohydramnios, caused by reduced fetal urine production o Also used to suppress preterm labor if other methods fail and if less than 32 weeks gestation o Blocks production of prostaglandins, which relax uterine smooth muscle Oligohydramnios- o Less than 500 cc amniotic fluid o Fundal height out of proportion to gestational age o Cause unknown (Possibly caused by GU problem ) Amniotic fluid problems- o Postmaturity with IUGR o Fetal renal anomalies o May increase risk of cord compression during labor Amniofusion- o May be used to replace some fluid during labor to remove compression o Indications: o Fetal distress o MAS o If there is meconium stained amniotic fluid you would do this to rinse/dilute the fliud so baby is not swallowing it Premature rupture of membranes- o PROM: premature rupture and leakage beginning at least one hour before onset of labor at any gestational age water is broken but she is not in labor o PPROM: preterm premature rupture of membranes, less than 37 completed weeks membranes are ruptures at least an hour before labor and less than 37 weeks o Predisposing factors: cervicitis, UTI, incompetent cervix, placenta previa, abruptio placenta, hydramnios, trauma, multiple pregnancy, smoking, substance abuse, fetal anomalies Don’t really know what causes it most of the time o Risks of premature rupture of membranes Maternal Risks Chorioamnionitis-bacterial infection of amniotic cavity Endometritis-uterine infection Fetal/Neonatal Risks Preterm delivery leading to RDS Prolapsed cord Clinical Management: Assess fluid with nitrazene or fern test Vaginal cultures: GBS status Monitor fetal status Less than 37 weeks: Assess fetal lung maturity Possible use of prophylactic antibiotics Possible use of corticosteroids Tocolytics contraindicated Give corticosteroids btwn 24 and 34 weeks gestation Tocolytics contraindication r/t risk of infection Prolonged rupture of membranes- o Greater than 24 hours prior to birth o Increases risk of infection o May need cervical ripening or oxytocic induction Preterm Labor- o Maternal Risk: psychological stress, concern for infant o Fetal and Neonatal Risks: preterm delivery leading to RDS (respiratory distress syndrome) o Diagnosis: gestational age 20-37 weeks o Documented contractions o Progressive cervical change o Predisposing factors Multiple gestation Cervical incompetence Hydraminos Uterine anomaly Maternal infection Maternal medical disease Previous preterm labor Uterine irritability Age less than 18 or greater than 35 Low SES Substance abuse Poor weight gain Non-white race In-vitro fertilization STD’s Anemia Abdominal trauma o Signs and symptoms- Uterine contractions every 10 minutes or less, for at least one hour Lower abdominal or back discomfort Pelvic pressure or heaviness Urinary frequency or diarrhea Vaginal discharge: change in character or amount Vaginal bleeding Possible ruptured membranes o Self-management- Empty bladder Full bladder will cause uterine irritability Drink 2 or 3 glasses water or juice Lie down on side for one hour Palpate for contractions If symptoms persist, call health care provider If symptoms go away, resume only light activities o Home monitoring and care Void every 2 hours Consume 2-3 quarts of fluid daily Avoid lifting Avoid nipple stimulation Limit sexual activity Limit activities Monitor uterine activity Nipple stimulation and sex causes oxytocin to release = go into labor o Medical Management- Monitor UC, FHR R/O UTI IV fluids Tocolytic therapy Magnesium Sulfate Terbutaline (Brethine) Nifedipine (Procardia) Indomethacin (Indocin) Betamethasone- help babies lungs mature Postterm Pregnancy- o Pregnancy extends beyond 42 completed weeks o Cause: unknown o Possibly deficiency of placental estrogen & continued secretion of progesterone o Maternal risks: dysfunctional labor, operative assisted delivery, trauma, PP hemorrhage o Placenta tends to give out and calcify after 42 weeks and a dec in amniotic fluid o Fetal risks: Uteroplacental insufficiency SGA LGA, birth trauma if no uteroplacental insufficiency Meconium aspiration Oligohydramnios > umbilical cord compression Birth Trauma- o Risk Factors o Soft Tissue Injuries: erythema, ecchymosis, petechiae, abrasions, lacerations, edema o Skeletal Injuries, especially clavicle o Peripheral Nervous System Injuries, especially brachial plexus o CNS Injuries Induction of Labor- o Assessing readiness of cervix for delivery using the Bishop Score o Scale to let us know how prepared cervix is for delivery, need at least a score of 8 or higher o o o 0 o 1 o 2 o 3 o Cervical o Closed o 1-2 cm o 3-4 cm o > 5 cm Dilatation o o Cervical o 0-30% o 40-50% o 60-70% o > 80% effacement o o Fetal Stationo -3 o -2 o -1,0 o +1,+2 o Cervical o Firm o Medium o Soft o Soft Consistency o Cervical o Posterior o Midposition o Anterior o anterior Position Cervical Ripening- o Cervidil (dinoprostone) -> know the D name Small tampon like cloth, goes in vagina, behind cervix and releases medicine, usually receives at night before given Pitocin, has a string so if you need to you can pull it out quickly o Nursing care: Monitor VS NST Keep pt supine with hip tilted to left for 1 hour, continue to monitor VS and EFM Watch for hyperstimulation of uterine contractions o Gel should be removed if there is severe nausea, vomiting, or hyperstimulation. o What other treatment could be used in the event of hyperstimulation? Give her a fluid bolus or give tributilene if it severe enough Change position (side-lying) Oxytocin Administration (induction of labor) o Give Pitocin if: PROM Chorioamnionitis Postterm gestation IUGR, fetal demise o Contraindications: Placenta previa Transverse fetal lie Prolapsed umbilical cord Prior classical uterine incision vertical incision in uterus, after this all pregnancies must be C section Active genital herpes CPD Rigid, unripe cervix Severe PIH Fetal distress o Meternal and Fetal effects of Pitocin Maternal: Placental abruption Impaired uterine blood flow Rapid labor Uterine rupture Water intoxication Fetal: Hypoxia if hyperstimulation occurs Trauma from rapid birth If given too much or too quickly: Water intoxication b/c it has a antidiuretic effect o Nursing Considerations- Apply fetal monitor for at least 15-20 minutes prior to starting infusion to obtain baseline Maintain continuous EFM throughout induction o Nursing Considerations for Pitocin Induction of Labor Usually 20 units pitocin added to 1 L of fluid (5D/RL), result in 1 mU/minute = 3 cc/hr), maximum rate is 20 mU/minute. Additional plain IV fluid is connected to administer fluids Pitocin goes in the lowest port Infusion pump is used with pitocin Initial dose is started at 1-2mU/minute with increases every 30minutes Assess FHR, maternal VS, and UC prior to each increase in rate Maintain I&O Assess and document everytime before you increase it Discontinue IV oxytocin infusion if: Any signs of fetal distress Uterine contractions more frequent than every 2 minutes Needs at least 60 secs of resting time between each contraction Duration of contractions greater than 90 seconds Insufficient relaxation of uterus between contractions Forceps- o Provide traction and rotation o Types Outlet Low Midforceps Piper o Risks- Lacerations Hematomas Facial palsy Infant bruising or abrasions Maternal bladder or urethral injuries o Prerequisites for use- Fully dilated Bladder empty Presenting part engaged Vertex if possible No evidence of CPD Vacuum Extractor- o Suction applied to fetal head to assist in rotation and descent o Vacuum is used to shorten the second stage o Risks: Cephalhematoma Scalp lacerations Subdural hematoma o o Caput Succedaneum-Shape of babies head after vacuum is used Cesarean Delivery Indications- o Breech o Multiple gestation o Preterm infant o Fetal distress o CPD o Previous classical cesarean incision o Dysfunctional labor o Active genital herpes o Placenta previa o Abruptio placenta o Prolonged ROM o Severe PIH o Umbilical cord prolapse o Risks- Increased risk of infection Increased risk of hemorrhage Reactions to anesthesia agents Blood clots Maternal/infant bonding interference o Preparation- Choice of anesthetic Presence of support person IV line Baseline EFM NPO Foley catheter Abdominal prep VS Pelvic tilt Type and screen o Postop care- Same care as for abdominal surgery, with added dimension of PP care Assessment of blood loss Lochia Fundus VBAC (vaginal birth after c section)- o Candidates: Previous low transverse C/S In facility that can perform a C/S within 30 minutes Physician is available o Risks: Hemorrhage Uterine rupture o Trial of Labor- Four to six hours For VBAC, questionable pelvis, or abnormal presentation
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