Complications of labor and birth

Premature Rupture of Membranes

(PROM)
Is the spontaneous rupture of fetal membranes one

hour or more before the onset of labor.

Incidence: 10% of all pregnancies.
Causes: remains unknown in most cases.

Risk factors:
Polyhydaminos

Cerculage
Amniocentesis
Placental abruption.

Infection
More common in twins gestation.
Seldom associated with trauma.

Complications
1. Preterm delivery.
2. Maternal or fetal infections:
a) Chorioamniositis
b) Endometrits
clinically persisting
after delivery.
3. Fetal distress
a) Umbilical prolapsed more common in cases of
PROM.
b) Increase rate of stillbirths in unmonitored
patients.

Evaluating the patient with PROM

Correct diagnosis is essential for future

management.
Sterile speculum examination:
Visualize

pool of fluid in vaginal fornix

Leakage of fluid through cervix.
pH of amniotic fluid is 7.1 to 7.3
Normal vaginal pH is 4.5 to 6

Nitrazine paper turns blue at pH > 6.5

Note: false positive rates (1% to 17%) by blood, semen,

vaginal infection, alkaline antiseptics or alkaline urine.

Evaluating the patient with PROM

Cervical dilation is assessed.
Observe for prolapsed fetal part or umbilical cord.

Collection of samples for culture.

Collection of fluid for lung maturity studies.
Note: don't perform digital intracervical examination

in nonlaboring patient.
Ultrasound is a final confirmatory step in some cases.
Establish gestational age and fetal maturity (history,
u/s, and other dating criteria).
Rule out infection: clinical manifestation e.g. fever and
cultures.
Rule out fetal distress: continuous fetal heart tone
monitoring.

Management and interventions

Term patients:
Immediate induction is suggested.

Preterm patients:
Survival rate after 26 weeks is close to 50%.
If gestation is < 34 weeks, efforts are directed toward
maintaining pregnancy. Tocolytic to delay labor long enough
for fetal lungs to mature with administration of
corticosteroids.
Antibiotics therapy
Nurse monitors vital sings and describe the characters of the
amniotic fluid, uterine activity, fetal response to labor and
hydration.

Uterine rupture
Uterine rupture is a

spontaneous or
traumatic rupture
of the uterus.

Causes:
Rupture of the scar from a previous cesarean delivery or

hystrotomy.
Uterine trauma
Congenital uterine anomaly.
Prolonged or obstructed labor.
Forced delivery of fetus with abnormalities e.g.
hydrocephalus.
Internal or external version.
Application of forceps and extraction before cervical os
has completely dilated.
Injurious use of oxytocin.
Excessive manual pressure applied to the fundus during
delivery.

Clinical manifestation
1. Complete rupture:
Sudden sharp abdominal pain during contractions.
Abdominal tenderness.
Cessation of contractions.

Bleeding into abdominal cavity and sometimes into

vagina.
Fetal easily palpated, fetal heart tones cease.
Signs of shock.

Clinical manifestation
2. Incomplete rupture:
Develops over a period of few hours.
Abdominal pain during contractions.
Contractions continue, but cervix fails to dilate.

Vaginal bleeding may be present.

Tachycardia, pale skin.
Loss of heart tones.

Management and nursing intervention

Emergency laparotomy is performed with complete

rupture, usually the uterus is removed and attempts

are made to save the baby.
Administer IV fluids and blood as directed.
Administer oxygen to the woman.
Prepare the woman for emergency surgery.
Monitor maternal and fetal vital signs until surgery
begins.
Uterus may be repaired if rupture is not extensive, if
extensive hysterectomy is necessary.

Management and nursing intervention

Reduce fear and anxiety:
Keep the woman informed about procedures being done.
Answer her questions as positively and as realistically as

possible.
Fetal prognosis is very poor, unless delivery can be
accomplished immediately.
Maternal prognosis is guarded, especially in uterine
rupture of traumatic origin (5-10 % mortality).
If fetus doesn't survive, offer grief counseling.
If the uterus is spared, woman is advised to have
cesarean birth with future pregnancy.

Amniotic fluid embolism.

Is the accidental infusion of amniotic fluid in to the mother's

blood stream under pressure from the contracting uterus.

Amniotic fluid containing fetal vernix, lanugo, meconium, and
mucus enters maternal blood sinuses through defect's in to
the placental attachment.
These particles become emboli in the mothers general
circulation causing acute respiratory, circulatory collapse,
hemorrhage and cor pulmonale as they block the vessels of
her lungs.
These particles stimulate abnormal coagulating, initiating
DIC.
Amniotic fluid embolism is rare and usually fatal (mortality
rate is as high as 80% for mothers & approximately 50% of
neonates)

Clinical manifestations:
Sudden dyspnea and chest pain.

Cyanosis.
Tachycardia.
Pulmonary edema.

Prolonged shock due to:

1. Anaphylaxis, which cause vascular collapse.
2. Uterine bleeding with development of hypofibrinogenemia.

Management and nursing intervention

Emergency measures: cardiopulmonary resuscitation (CPR).

1. Improving tissue perfusion and cardiopulmonary function.

2. Administer O2 as soon as possible.
3. Provide assisted ventilation.
4. Maintaining fluid volume and correction of DIC.
5. Administer fresh whole blood and fibrinogen.
6. Administer IV fluids and plasma.
7. Provide continuous monitoring of maternal and fetal status.
8. Delivery of fetus.
9. Since fetus is in great danger, cesarean approach is used.
10. Care for the neonate and provide family members with
comfort and information about the status of mother and
infant.

Prolapsed Umbilical Cord

Occurs when a loop of the umbilical cord slips down

below the presenting part of the fetus.

Types
Occult prolapse (hidden; not visible), occurs at

any time during labor whether or not the membranes

have rupturedthe cord lies beside the presenting
part in the pelvic inlet.
Complete prolapse, the cord descends into the
vagina, where it is felt as a pulsating mass on vaginal
examination. It may or may not be seen.
Frank (visible) prolapse, most commonly occurs
immediately after rupture of membranes as gravity
washes the cord in front of the presenting part.

Causes
Rupture

of membranes, when the presenting part

is not engaged in the pelvis.
More common in shoulder & foot presentation.
Prematurely: small fetus allows more space around
presenting part.
Hydramnios: causes greater amount of fluid to be
related with greater force when membranes
rupture.
Contracted pelvis.
Placenta previa.

Clinical Manifestation
Cord may be seen protruding from vagina, or can be

palpated in the vaginal canal cervix.

Signs of fetal distress: the cord is compressed
between the presenting part and bony pelvis.
If cord is exposed to cold room air, there may be
reflex constriction of umbilical vessels, restricting
oxygen flow to fetus.
Fetal heart rate pattern may be irregular with
periodic fetal bradycardia.

Management & Nursing Interventions

Maintaining oxygen supply to fetus:
Until the presenting part has engaged, all women whose

membranes have ruptured should remain on bed rest.

At the time of spontaneous rupture or amniotomy, FHR is
assessed continuously, if bradycardia is noticed, assess for
cord prolapse.
Place the women in recovery or knee-chest position.
Administer oxygen to the women.
Place sterile gloved hand in vagina and push the fetal head up
ward to relief compression of the cord.
Prepare of immediate vaginal delivery if cervix is dilated.
Prepare of immediate cesarean delivery if cervix is not
deleted.
In home situation, cover-protruding cord with clean wet
dressing. Elevate the woman's hips and transports to hospital
immediately.

Management

Management
Reducing Anxiety:
Have the woman/couple hear fetal heart tones for
reassurance.
Keep the woman informed of procedure being
performed.
When infant is born and stabilized, have the
woman/couple hold him as soon as possible for
reassurance.

Uterine Inversion
Uterine inversion (uterus is turned inside out) is a

rare but potentially life-threatening complication.

Possible causes:
Most common cause is excessive pulling on the
umbilical cord in an attempt to hasten the third stage
of delivery.
Other contributing factors include vigorous fundal
pressure, uterine atony, and abnormally adherent
placental tissue.

Clinical Manifestations
When complete inversion occurs, a large, red,

globular mass (that may contain the still-attached

placenta) protrudes 20 to 30 cm outside the vaginal
introitus.
A partial or incomplete inversion is not visible;
instead, a smooth mass is palpated through the
dilated cervix.
Maternal symptoms include pain, hemorrhage, and
shock.

Management

Involves manual replacement of the fundus (under

general anesthesia) by the physician, followed by

oxytocin to facilitate uterine contractions and
antibiotic therapy to prevent infection.
Prevention (by not pulling strongly on the cord until
the placenta has fully separated) is the safest and
most effective therapy.

Labor Complicafions
Dystocia

Defined as a long, difficult or abnormal labor, is a term used to

identify poor labor progression.
Predisposing factors Etiology"
Any problem with powers (uterine contractions), the passenger
(fetus), or the passageway (maternal pelvis).

Dystocia
Predisposing factors Etiology"
Any problem with powers (uterine contractions), the

passenger (fetus), or the passageway (maternal pelvis).

Hypertonic or hypotonic uterine contractions.
Multiple gestations.
Abnormal implantation site of the placenta.
Contracted pelvic.
Fetopelvic disproportion.
Large baby.
Malposition and malpresentation.
Previous experience.
Poor support system.

Types of Dystocia
1. Mechanical dystocia:
Maternal causes: contracted pelvis, obstructive tumor
Fetal causes: malformation of the fetus as hydrocephalus

or large size baby, malpresentation as shoulder, face or

breech.
2. Functional dystocia: (uterine dysfunction or inertia).
Condition in which uterine contractions deviate from the
normal contractions may be extremely forceful with a rapid
and traumatic labor, more commonly, the contractions are
ineffectual.

Hypotonic uterine contraction (inertia)

Defined as less than 3 contractions of mild to

moderate intensity occurring in a 10 minutes period

during the active phase of labor.
The intrauterine pressure (IUP) is insufficient for the
progression of cervical effacement and dilation.
Cervical dilation and descent of fetus slow greatly or
stop.

 Hypotonic uterine contraction (inertia)

Etiology:
Occurs when uterine fibers are overstretched from large

baby, twins, hydramnios, or multiparity.

May also be caused by administration of sedations or
narcotics.
Bowel or bladder distention.

Contractions

Complications of inertia
Potential maternal effects:
Exhaustion.
Postpartum hemorrhage.
Stress and psychological trauma.
Infection.

Potential fetal effects:

Fetal sepsis (Infection).
Fetal and neonatal death.

Medical management
Walking and position changes in labor assist in fetal

descent through the maternal pelvis and therefore

need to be encouraged.
The use of relaxation techniques & massage can
decrease the need for pharmacological agents for
pain.
Oxytocic stimulation of labor or prostaglandin
stimulation.

Nursing intervention
Pelvis is reevaluated for size.
IV fluids are provided to maintain hydration and

electrolyte balance.
Oxytocin administration is started if pelvic size is
adequate, fetal position and presentation is normal.

Monitor FHR and contractions, if contractions last more than 60-70

seconds, decrease or stop infusion to prevent rupture of uterus
and premature separation of the placenta and fetal hypoxia.
Observe IV drip, be certain that infusion is running at the
prescribed rate.
Report any maternal or fetal distress immediately.

Amniotomy may be performed to augment labor.

Use anxiety-reducing measures to promote

psychological and emotional status.

Hypertonic uterine contraction

Usually occurs in the latent phase of labor, with an

increase in frequency of contractions and a

decrease in their intensity.
Contractions are strong and often painful but are
ineffective in producing cervical effacement and
dilation.

Hypertonic uterine contraction

An increase in maternal catecholamine release (i.e.,

epinephrine, norepinephrine) can result in poor uterine

contractility. Uterine pacemakers (the energy source of
contractions located in the uterine wall) do not initiate a
good myometrial response needed for progressive
cervical change. Instead, irregular spasmodic episodes
occur that do not result in effective contractions or assist
in bringing the fetus into a more favorable downward
position
Contraction may be uncoordinated and involve only
portions of the uterus.
Usually occurs before 4 cm dilation. The cause is not yet
known, may be related to fear or tension.

Possible causes
Potential maternal causes:
Maternal anxiety (Primiparous labor, Loss of control, Sexual
abuse, Lack of support, Cultural differences, Fear of pain)
Potential fetal causes:
occiputposterior malposition

Medical management
Analgesic (morphine, meperdine) if membranes

are not ruptured and fetalopelvic disproportion isn't

present.
Natural labor with effective contractions often
resumes after this simple intervention.
Nonpharmacological techniques to reduce anxiety
facilitate rotation of the fetal head into a more
favorable position (walk and change positions
frequently).

Nursing intervention
Bed rest & sedatives to promote relaxation and

reduce pain.
Provide fluids to maintain hydration and
electrolyte balance.
Observe for normal contractions when woman
awakens.
Oxytocin is not administered; it will increase the
abnormal labor pattern.
Check intake and output every 2 hr.
Monitor vital signs and FHR.
If the condition is prolonged, check for CPD and
malpresentation, if excluded, amniotomy and
oxytocin infusion may be instituted.

Contracted pelvis
The bony funnel of the womans pelvis is too

narrow at some point for the fetus to pass through

Pelvic diameter is1 cm or more less than normal
(except transverse, diameter 2 cm)
Causes:

Growth retardation.
Growth disease e.g. T.B.
Bone disease e.g. rickets.

Determine condition of pelvis by X- ray or

ultrasound

Cephalopelvic disproportion
Is fetal head to maternal pelvis discrepancy.
The term is also used with other positions.

CPD is suspected when labor is prolonged, cervical dilatation

and effacement are slow and engagement of the presenting

part is delayed.
Trial labor is allowed to continue only as long as dilation and
descent progress.

Cephalopelvic disproportion
If there is no progress, cesarean birth is performed.

Nursing care as contracted pelvis and other

complicated labors.
Maternal complications of such labor include PROM,
uterine rupture and necrosis of maternal soft tissue
from pressure of the fetal head.
Fetal complications include cord prolapse, extreme
molding of the skull with possible fractures and
intracranial hemorrhage.

Multiple pregnancies
Introduction of ovulation inducing agents in late

1960s and assisted reproductive technologies (ART)

in the 1970 caused increased number of multiple
births.
Much of perinatal mortality and morbidity
attributable to multiple births is due to preterm
delivery.
Twin gestation:
1% all births.
Represent a high-risk pregnancy.

Types of twining:
Monozygotic (identical): are identical because

they develop from fertilization from one fertilized

oocyte (zygote) that divides into equal halves during
an early cleavage phase (series of mitotic cell
divisions) of development. If division occurs early
(first 1-8 days), they will have two placentas. If it
occurs later, they will share the same placenta.

Monozygotic

Dizygotic (fratermal):
Occurs more frequently in some families "heredity is

important on mothers side".

Occurs in response to greater levels of FSH.
Increased in women greater than 35 years of age and in
obese women.
More common among Africans (10 to 40/1000).
May be different sexes.
Always have 2 chorions, 2 amnions.
Result from fertilization of 2 separate ova.
Fertility drug use associated with dizygotic twinning such
as clomide and pergonal.

Complications
Maternal complications:
Greater increase in blood volume, pulse, cardiac output and
weight gain.
Increased rate of preterm labor, hypertension, abruption,
anemia, hydramnios, UTI, cesarean section and postpartum
hemorrhage.

Infant complications:
Prematurity average age of delivery is 37 weeks.
Difference in placental surface area.

Donor twin small, pale, anemia.

Recipient twin large, plethoric, polycythemia,

hyperbilirubinemia.

Fetal anomalies occur more often in multiple pregnancies.

Triplets
Increasing frequency because of ART.

Average weight gains 45 to 50 pounds.

Usual spontaneous time for delivery is 32-34 weeks.
Average weight of newborns is1800-1900 grams.

Most delivered by cesarean section.

Quadruplets or more:
Most are a result of ART.

Average gestational age 30 to 31 weeks.

Average weight newborns weight is1200-1500

grams.
Multifetal reduction, has been shown to improve
perinatal survival rate.

Assessment:
Initial maternal assessment includes a family history

of twinning or use of fertility drugs.

At each prenatal visit, assess fundal height, FHR,
fetal development.
U/S to confirm the diagnosis.
Assessment of physical discomforts such as backache
and dyspnea.
Multiple pregnancies increase the incidence of PIH,
prematurity, hydramnios, abnormal fetal positions
and presentations, uterine dysfunction, and
postpartum hemorrhage.

Nursing intervention:

To prevent premature delivery:

Encourage the woman to keep appointments for more frequent

checkups.
Counsel the woman to rest frequently during the day especially
in the third trimester; assist the family to mobilize support
system for this purpose.
Teach the woman reportable signs and symptoms of
premature labor.
Diet high in protein, iron, calcium, 300 calories added to
normal pregnancy.
Monitor for hypertensive disorders.
During labor, mother and fetuses are monitored closely.
Ideally, the largest fetus is delivered through vertex
presentation and is the first to be born. If the first is a breech
presentation or the smaller one, delivery is complicated.
Cesarean birth is recommended if fetal distress, CPD, placenta
previa, or sever PIH is present or if prior cesarean birth have
occurred.
Following delivery, monitor the woman for postpartum

Health education:
Rest frequently on her side.

Sitting with leg elevated to help relief backache.

Small frequent meals will aid digestion.