Complications of

Labor and Delivery

Barbara A. Evans, RN, MSN

Aquinas College
ASN Program
Fall 2009
 Crucial for Nurses to:

• Understand normal birth process

• Prevent and detect deviations from normal labor

and birth

• Implement nursing measures if complications

arise
Essential Forces of Labor

• Powers

• Passage

• Passenger

• Psyche
Problems with the Powers

• Dysfunctional Labor --

“abnormal uterine contractions that prevent

the normal progress of cervical dilation,
effacement or descent.”
Wong, et al
(2006)
Ineffective Uterine Forces

• Hypotonic Contractions

• Hypertonic Contractions

• Ineffective Contractions
Hypotonic Contractions

Also called Secondary Uterine Inertia

Usually in Active Phase of labor

• Maternal Effects
• Fetal Effects
• Medical Treatment
• Nursing Care
Hypertonic Contractions

Primary Dysfunctional Labor

• Maternal Effects
• Fetal Effects
• Medical Treatment
• Nursing Care
Ineffective Contractions

• Maternal Effects
• Fetal Effects
• Medical Treatment
• Nursing Care
 First Stage Dysfunction

• Prolonged Latent Phase

• Prolonged Active Phase
• Prolonged Descent
• Prolonged Labor
 Prolonged Labor

Labor that lasts more than 24 hours

(latent/active phase combined)

• Maternal Effects
• Fetal Effects
• Medical Treatment
• Nursing Care
Second Stage Dysfunction

• Arrest of Descent

• Failure of Descent

• Dystocia
Will discuss in more detail later
 Precipitous Labor

“an intense, unusually short labor (less

than 3 hours)”

Maternal-Child Nursing (2000)

 Precipitate Labor

• Maternal Implications
• Fetal Implications
• Medical Treatment
• Nursing Care
 Post Dates Pregnancy

• Pregnancy that lasts > 42 weeks

• Physical risk to fetus
• Utero-placental insufficiency
• Respiratory Distress of newborn
• Growth restriction of fetus
 Uterine Rupture

• Very serious obstetric injury

• Most frequent causes
• Separation of scar of previous classic cesarean
birth
• Uterine trauma: accidents, surgery
• Congenital uterine anomaly
 Uterine Rupture

• Causes
• Signs/Symptoms
• Maternal Effects
• Fetal Effects
• Management
• Complications
 Uterine Inversion

Defined as “when the

uterus completely or
partly turns inside out,
usually during the
3rd stage of labor.”
Maternal-Child Nursing (2000)
 Amniotic fluid embolism (AFE)

• Amniotic fluid containing particles of debris

• Vernix, hair, skin cells, or meconium enters
maternal circulation

• Obstructs pulmonary vessels

• Causes respiratory distress and circulatory

collapse
Amniotic Fluid Embolism

• Maternal Effects
• Fetal Complications
• Medical Treatment
• Also termed “Anaphylactoid Syndrome of
Pregnancy”
Problems with the Passenger

• Prolapse of Umbilical Cord

• Multiple Gestation
• Fetal Malpresentation
• Macrosomia
• Shoulder Dystocia
Prolapsed umbilical cord

• When cord lies below presenting part of

fetus
• Contributing factors include:
• Long cord (longer than 100 cm)
• Malpresentation (breech)
• Transverse lie
• Unengaged presenting
part
Prolapse of Umbilical Cord
Note pressure of presenting part on umbilical cord, which endangers
fetal circulation
A. Occult (hidden) prolapse of cord
B. Complete prolapse of cord. Note that membranes are intact
C. Cord presenting in front of fetal head may be seen in vagina
D. Frank breech presentation with prolapsed cord
Prolapsed Umbilical Cord

• Maternal Effects
• Fetal Effects
• Medical Treatment
• Nursing Care
 Multiple Gestation
• Twins 1/99
• Triplets 1/500
• Quads 1/400,000

• Maternal Effects
• Fetal Effects
• Medical Treatment
• Nursing Care
External Version of Fetus from Breech to Vertex Presentation
This must be achieved without force
A. Breech is pushed up out of pelvic inlet while head is pulled toward inlet

B. Head is pushed toward inlet while breech is pulled upward

A B
 Fetal Malpositions and
Malpresentations
• Maternal Implications
• Fetal Effects
• Medical Treatment
• Nursing Care
 Macrosomia

• Macro = large
• Soma = body

• >9.5 lbs

• Common in IDM babies

 Macrosomia

• Maternal Effects
• Fetal Effects
• Medical Treatment
• Nursing Care
 Shoulder dystocia

• Head is born, but anterior

shoulder cannot pass
under pubic arch
• Newborn is more likely to
experience birth injuries
• Mother’s primary risk stems from excessive
blood loss, lacerations, extension of
episiotomy, or endometritis
Application of Suprapubic Pressure
A. Mazzanti technique: pressure is applied directly posteriorly and laterally
above the symphysis pubis
B. Rubin technique: pressure is applied obliquely posteriorly against the
anterior shoulder

A B
McRoberts Maneuver
 Problems with the Passage

Dystocia
Pelvic dystocia
Contractures of pelvic diameters that reduce the
capacity of the bony pelvis, inlet, midpelvis, or
outlet

Soft-tissue dystocia
Results from obstruction of the birth passage by
an anatomic abnormality other than the bony
pelvis
Therapeutic Management of
Problems/Potential Problems
• Cervical Ripening
• Cytotec

• Induction of Labor
• Amniotomy
• Oxytocin Infusion

• Augmentation of Labor
Induction/Augmentation of Labor

• 2 types
• Elective
• medical
• Contraindications
• Assessment for readiness
• Fetal
• Maternal
• Augmentation
 Amniotomy

• Disadvantages
• Advantages
• Nursing Responsibilities
 Oxytocin Infusion

• IV for induction
• Begin at 0.5-2mu/min
• Increase 0.5-2mu/min every 15-60 minutes
• Risks of Administration
• Nursing Care
 Other Complications

• Oligohydramnios
• Polyhydramnios
• Intrauterine Fetal Death
 Oligohydramnios

• Defined as < 500ml between 32 and 36

weeks gestation
• Common Causes
• Maternal and Fetal Effects
• Medical Treatment
• Nursing Implications and Care
Hydramnios or Polyhydramnios

• Defined as exceeding 2 Liters between 32

and 36 weeks gestation
• Association with condition
• Maternal and Fetal Effects
• Medical Treatment
• Nursing Care
Intrauterine Fetal Death (IUFD)

Physical and
Psychological Concerns

Assessment
Medical Treatment
Nursing Interventions
 Instrumental Deliveries

• Forceps Delivery
 Care Management
Forceps-assisted birth

Maternal indications
Shorten second stage in event of dystocia
Compensate for deficient expulsive efforts
Reverse a dangerous condition

Fetal indications
Distress or certain abnormal presentations
Arrest of rotation
Delivery of head in a breech presentation
Outlet forceps–assisted extraction of the head

Types of forceps
Piper forceps are used to assist delivery of the
head in a breech birth

Tucker-McLean
 Instrumental Deliveries

• Forceps Delivery
• Vacuum Extraction
 Care Management
Vacuum-assisted birth

Attachment of vacuum cup to fetal head, using

negative pressure to assist birth of head

Prerequisites
Vertex presentation
Ruptured membranes
Absence of CPD
Use of Vacuum Extraction to Rotate Fetal Head and Assist with Descent
A. Arrow indicates direction of traction on the vacuum cup
B. Caput succedaneum formed by the vacuum cup
 Fetal Distress

Reassuring Patterns
Non-Reassuring Patterns
Fetal Scalp Stimulation
Physiological Goals and Nursing
Interventions
 Fetal Heart Rate
• Characteristic Patterns
• Tachycardia
• Bradycardia
• Variability
• Absent
• Minimal
• Moderate
• Decelerations (late and variable)
• Interventions
 Cesarean Birth
• Why? • Preop
• Scheduled • Assessment
• Emergency • VS
• Lab Studies
• Teaching
• Consent
• Prep for Surgery
• Preop meds
• Support person
Cesarean Birth: Skin and Uterine Incisions

A. Classic: vertical incisions of skin

and uterus

B. Low cervical: horizontal incision

of skin; vertical incision of uterus

C. Low cervical: horizontal incisions

of skin and uterus
 Bibliography
• Feinstein, N. Torgersen, K. L., & Alterbury, J. (2003).
Fetal Heart Monitoring Principles and Practices.
Kendall/Hunt Publishing Company: Dubuque, IA.
• Mattson, S. and Smith, J. E., (2000). Core Curriculum for
Maternal-Newborn Nursing. W. B. Saunders Company:
Philadelphia
• McKinney, E. S., Ashwill, J. W., Murray, S. S., James, S.
R., Gorrie, T. M. & Droske, S. C. (2000). Maternal-Child
Nursing, W. B. Saunders Company: Philadelphia.
• Pilliterri, A. (2002). Maternal & Child Health Nursing (4th
ed.). Lippincott: Philadelphia.
 Bibliography
• Wong, D. L., Hockenberry, M. J., Perry, S. E.,
Lowdermilk, D. L., & Wilson, D. (2006). Maternal Child
Nursing Care (3rd ed.). Mosby: St. Louis, MO.
• www.fetalmonitorstrips.com/learn_more.html