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
A. Occult (hidden) prolapse of cord

Note pressure of presenting part on umbilical cord, which endangers fetal circulation

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

• Macro = large • Soma = body • >9.5 lbs • Common in IDM babies


• • • •

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



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

• 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

• 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


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?
• Scheduled • Emergency

• Preop
• • • • • • • • Assessment 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

• 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.

• 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. •

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