October 26, 2016 – 1

Complications of Labor and Birth PowerPoint Outline

I. Care of The Woman with A Psychological Disorder:
a. Psychological Disorders are characterized by alterations in:
i. Moods
ii. Behavior
iii. Or thinking
b. Specific Problems –
i. Anxiety disorders:
1. Panic disorder –
a. Can experience intense feelings of terror w/o warning during labor
b. Physical symptoms coincide with feelings –
i. Chest pain / SOB / Weakness / Fainting
ii. “Ritualistic” behavior helps minimize
2. OCD
3. PTSD
4. Phobias
ii. Personality disorders
iii. Depression:
1. During labor, may complicate her ability to concentrate/process information given
2. May present with sleep deprivation
3. Little reserves to draw from making her seem irritable or withdrawn as labor progresses
iv. Schizophrenia:
1. Difficult to treat during pregnancy
2. Most meds are contraindication
3. Pt may have hard time with emotions and thinking clearly
c. Need history of – diagnosis, current meds, last taken
II. Precipitous Labor and Birth:
a. Rapid birth < 3 hours total
b. Maternal Risks –
i. Hemorrhage
ii. Cervical, vaginal, or rectal lacerations
c. Fetal Risks –
i. Hypoxia caused by decreased perfusion to intervillious spaces
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d. Nursing Management –
i. Assessment –
1. Identify risk for a precipitous labor
ii. Stay w/ client
iii. Use sterile gloves
iv. Instruct client to blow to decrease urge to push
v. Support perineum with sterile towel as crowning occurs
vi. Apply gentle pressure on fetal head to prevent rapid delivery
III. Post-term (postdates) Pregnancy:
a. Fetal Risks –
i. Hypoglycemia
1. Nutritional deprivation r/t depleted glycogen stores
ii. Meconium aspiration
1. Response to hypoxia
iii. Polycythemia
1. Due to increased production RBCs; baby looks red
2. Increased risk for jaundice
iv. Congenital anomalies
1. Unknown why
v. Seizures
1. Due to hypoxia
vi. Cold stress
1. Due to loss of subcutaneous fat
b. Clinical Management –
i. Confirm gestational age
ii. Ultrasound, NST, CST
iii. Bishop scoring
iv. Ripen cervix with Cervidil or Cytotec to induce labor
v. Amnioinfusion – instillation of warm sterile normal saline into uterus
1. Used to treat variable decelerations when oligohydramnios is present
a. May be necessary with any birth
b. Increased risk with post-term
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IV. Fetal Malpresentation: (Often not able to vaginally deliver)

a. Brow – fetal forehead
b. Face – chin/Mentum
c. Military – large diameter of head
d. Breech – feet or buttocks
e. Maternal Risks –
i. Increased risk of prolonged labor and operative procedure
f. Fetal Risks –
i. Do not place internal electrode on face
1. Edema and bruising of face, eyes and lips can occur
g. Clinical management –
i. Cesarean birth
h. Nursing management –
i. Continued assessment of mom and fetus
V. Fetal Malposition:
a. Ideal fetal position is flexed /w occiput in the right – or – left anterior quadrant of maternal pelvis
b. Malposition –
i. Types:
1. Occiput posterior (OP)
2. Occiput transverse (OT)
c. Maternal Risks –
i. Prolonged labor
ii. Possible cesarean birth
iii. Extension of episiotomy, lacerations
1. Symptom:
a. Intense back pain
d. Nursing Management –
i. Encourage mom to:
1. Lie on side
2. Knees-to-chest
3. Pelvic rocking
ii. Sacral pressure
iii. Support and encouragement
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VI. Multiple Gestation:

a. Dizygotic –
i. “Fraternal twins”
ii. Resulting from release of 2 separate ova and fertilization by 2 separate sperm
1. Usually have own placentas and membranes
b. Monozygotic –
i. “Identical twins”
ii. Single fertilized ova splits into 2 separate zygotes
1. Share placenta, but if cell division occurs within 3 days of fertilization
a. The zygotes will develop separate membranes
c. Maternal Risks –
i. Increased physical symptoms and discomforts, backaches
ii. SOB, pedal edema
iii. Preeclampsia, anemia
iv. Placenta previa, preterm labor and birth
d. Fetal Risks –
i. IUGR
ii. Congenital anomalies
iii. Abnormal presentations at time of birth
e. Clinical management –
i. Preventing preterm labor
ii. Intake of enough protein and other nutrients to sustain all babies
f. Nursing management –
i. Importance of bedrest
ii. Monitor for signs of complications
VII. Shoulder dystocia:
a. OB emergency resulting from inability to deliver one shoulder
b. Maternal Risks –
i. Lacerations and tears of birth canal
ii. Postpartum hemorrhage
c. Neonatal Risks –
i. Hypoxia
ii. Fracture of clavicle
iii. Injury to neck and head
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d. Nursing Management –
i. Assess for Risks:
1. Increased fundal height
2. Obesity
3. History of macrosomia
4. Maternal diabetes
5. Prolonged second-stage of labor
ii. Assist with positioning – DO NOT PANIC!
iii. McRobert’s maneuver –
1. Woman flexes thighs to her abdomen – knees to armpits
2. Position changes the:
a. Angle of the pelvis, pelvic diameter and facilitates delivery of shoulder
iv. Other maneuvers help change diameter of pelvic outlet and dislodge affected shoulder
VIII. Placental and Cord Problems:
a. Abruptio Placenta – premature separation of the placenta from the uterine wall
i. Bleeding, pain, ridged abdomen
ii. Can be varying degrees
b. Placenta Previa – abnormal implantation of the placenta low in the uterus near/covering the cervical os
i. Bright red, painless bleeding
ii. Hold all vaginal exams
c. Placental Infarcts and Calcifications –
i. High BP
ii. Affects transfer of oxygen and nutrients to fetus
d. Prolapsed Cord
IX. Prolapsed Umbilical Cord:
a. The fetus is not engaged—allows room for the cord to prolapse or come out of the cervix before the
baby
b. Factors –
i. ROM before engagement
ii. Small fetus
iii. Breech
iv. Multiple gestations
v. Transverse lie
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c. Goal –
i. Relieve pressure on cord
1. Sterile vaginal exam to push fetal head off cord
2. If cord protrudes through vagina:
a. Determine if pulsation is felt
b. Apply sterile soaked dressing to prevent drying
3. Place moms hips higher than her head
a. Trendelenberg or Knee-chest position
4. Administer oxygen 8-10 L/min
5. Assess fetal monitor
6. Prepare for rapid delivery vaginally (if completely dilated already) or cesarean birth (if
emergent)
X. Complications of the 3rd and 4th Stage of Labor:
a. Specific Problems –
i. Retained placenta
ii. Lacerations
iii. Placenta accreta, increta, and percreta
b. Maternal and Fetal Risks –
i. Infection
ii. Bleeding
iii. Accreta
XI. Placental Attachment Problems:
a. *Placenta Accreta –
i. The chorionic villi attached directly to the myometrium of the uterus
1. No clean separation
b. Placenta Increta –
i. Uterine muscle invaded
c. Placenta percreta –
i. Attached all the way through the uterine muscle
d. Can be life threatening
e. Adherence may be partial or total
f. 1:2500 occurrence
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XII. Amniotic Fluid Related Problems:

a. Normally 800-1,000 ml by 37 weeks gestation
b. Specific Problems –
i. Polyhydramnios – over 2000 mL of amniotic fluid
1. Problems → cord prolapse / room for growth
ii. Oligohydramnios – severely reduced amniotic fluid
1. Problems → movement / contractures and low tone / cord compression (V. Decels)
iii. Chrioamnionitis – inflammation and infection in the fetal membranes and amniotic fluid
1. Problems → ABD tender to tough / foul odor / concern about infection post birth
XIII. Uterine Rupture:
a. A tear or separation – in or of – the uterine wall
b. Causes:
i. Overstimulation with Pitocin
ii. Separation of previous cesarean section scar
iii. Uterine trauma
iv. Intense contractions
v. Difficult forceps delivery
vi. External cephalic version
c. Treatment –
i. Emergency operative delivery and often hysterectomy
d. Risk Factors –
i. Multiparity
ii. Multiple pregnancy
iii. Malpresentation
iv. Previous uterine surgery
e. Signs and Symptoms –
i. Sharp, sudden lower abdominal pain
ii. Tearing/ripping sensation felt by mom
iii. Signs of shock → increased pulse, low BP
iv. Absence of contractions
v. Fetal heart rate is undetectable
vi. Concealed bleeding
vii. Fetal parts felt in abdomen
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XIV. Uterine Prolapse:

a. Occurs when the uterus turns inside out through the introitus (“entrance”)
b. Commonly caused by vigorous massage of the fundus and pulling on the umbilical cord
c. Signs and Symptoms –
i. May report dragging sensation
ii. Pressure in vagina or visible mucosa
d. Treatment –
i. After childbirth – may require hysterectomy and repair of walls or packing the vagina to allow
the cervix to begin to close and hold the uterus in
XV. Assisted Delivery of the Baby:
a. Forceps –
i. Problems → bruising to fetus / lacerations to mother
b. Vacuum extraction –
i. Problems → tearing of scalp if only minimal hair present / won’t stick if too much hair
c. Indications:
i. Fetal distress
ii. Baby in OP position
iii. Baby “stuck”
iv. Maternal exhaustion
XVI. Cesarean Section:
a. Birth of the baby through an incision in the abdomen/uterus
b. Skin incision may be transverse (Pfannenstiel) or vertical (classical)
c. Uterine incision most often low transverse
d. Indications:
i. HSV
ii. Breech position
iii. CPD – “Cephalopelvic Disproportion”
iv. Fetal distress
v. Maternal PIH
vi. Placental abruption
vii. Placenta Previa
viii. Umbilical cord prolapse
ix. Arrested descent or failed induction
x. Uterine rupture
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XVII. VBAC:
a. Vaginal Birth After Cesarean
b. ACOG guidelines guide practice for MD’s
c. To be allowed to attempt a VBAC:
i. Must have previous low transverse uterine incision
ii. No previous uterine surgeries
iii. MD available for emergent delivery
iv. Anesthesia in house for duration of labor
d. Maternal and physician decision
XVIII. Intrauterine Fetal Death:
a. Stillbirth – occurs after 20 weeks gestation
b. Etiology –
i. Placental abruption, knots, or entanglement of the umbilical cord are most common
c. Fetal death may occur prenatally or during labor process
d. Maternal Risks –
i. If labor does not start → Disseminated Intravascular Coagulopathy (DIC) can occur
ii. Most moms will begin labor within 2 weeks of fetal death
e. Clinical Management – induction of labor if labor doesn’t begin
f. Nursing Management – Provide support
i. **NEVER SAY I UNDERSTAND OR YOU CAN HAVE ANOTHER BABY**
g. Stillborns have:
i. Maceration – peeling, red skin
ii. Soft and swollen heads with overriding skull bones
iii. Spalding’s sign – mouth open
XIX. DIC:
a. “Disseminated Intravascular Coagulation”
i. May occur when a nonliving fetus remains in utero
ii. Fetus releases thromboplastin into mom’s bloodstream → which activates the extrinsic clotting
system → and many tiny clots are formed
1. This depletes fibrinogen and the remaining blood cells are unable to clot
XX. Thrombus:
a. Occurs in response to thrombophlebitis (inflammation in the vein wall)
i. In this type of thrombosis, the clot is:
1. More firmly attached and is less likely to result in an embolism
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b. Predisposing Factors:
i. Obesity
ii. Increased maternal age
iii. High parity
iv. Anesthesia or surgery that resulted in vessel trauma
v. Prolonged bed rest
vi. Hypothermia
vii. Cesarean birth
viii. Heart disease
ix. Endometritis
x. Varicosities
xi. History of deep vein thrombus (DVT)
xii. Cigarette smoking
XXI. Assessment – Superficial Thrombus:
a. Symptoms become apparent 3rd / 4th day PP
i. Tenderness in portion of vein
ii. Local heat and redness is present, may have low-grade fever
iii. Pulmonary embolism is extremely rare
XXII. Assessment – DVT:
a. Frequently occurs in women with a history of thrombosis
b. Characterized by edema of the ankle and leg
c. Initial → low-grade fever / Followed by → chills and high grade fever
d. Pain located in lower leg or lower abdomen
e. Homan’s sign may or may not be positive
i. Calf pressure still elicits pain
f. Peripheral pulses may be decreased
g. May result in pulmonary embolism
i. Signs include → dyspnea / chest pain
XXIII. Assessment – Septic Pelvic Thrombophlebitis:
a. Infection ascends upward along the venous system and develops in the uterine, ovarian, or hypogastric
veins
b. Usually unresponsive to antibiotics
c. Characterized by abdominal or flank pain present with guarding
d. Occurs on 3rd or 4th day
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XXIV. Treatment for a Thrombus:

a. Assess Homan’s sign and VS
b. Document pain and site details
c. Bed rest
d. Provide warm moist heat as ordered
e. Elevate affected limb
f. Elastic stockings → TED hose
g. Administer heparin as ordered
XXV. Breast Infection – Mastitis:
a. An infection of the breast connective tissue
i. Primarily in women who are lactating
b. Usual causative organisms are:
i. Staphylococcus aureus / Escherichia coli / Haemophilus parainfluenza / Streptococcus species
c. Candida albicans can also cause mastitis
d. Signs and Symptoms –
i. Flu-like symptoms with sudden onset
ii. Breast consistency, nipple condition
iii. Warm, reddened, painful area
iv. Axillary lymph nodes enlarged or tender
v. Generalized fever
e. Predisposing Factors:
i. Traumatized tissue, fissured or crack nipples
ii. Engorgement, milk stasis or poor drainage, missed feedings
iii. Lowered maternal defenses caused by fatigue or stress
iv. **Poor hygiene practices**
v. Tight clothing or poor support of breast
f. Nursing Care:
i. Administer antibiotics, analgesics, and antipyretics
ii. Well-fitting supportive bra needed for 24 hours
iii. Promote adequate nutrition, hydration, rest and sleep
iv. Assess vital signs
v. Educate mom regarding breast care, proper latch on, let-down reflex, frequent breastfeeding,
and change of position during breastfeeding.
vi. CONTINUE nursing!!! Infection usually not transferred to breastmilk
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XXVI. Urinary Tract Infection:

a. Cystitis – lower urinary infection
b. Pyelonephritis – upper urinary tract infection
c. Predisposing factors:
i. Normal postpartal diuresis
ii. Increased bladder capacity
iii. Decreased bladder sensitivity from stretching or trauma
1. Following use of general or regional anesthesia
iv. Contamination from catheterizations
v. Obesity
d. Assessment –
i. Overdistention of the bladder in early postpartal period
ii. **Frequent urination of small amounts**
iii. Urgency
iv. Burning, dysuria
v. Hematuria
vi. Elevated temperature
1. Low-grade with cystitis
2. High-grade with pyelonephritis
vii. With pyelonephritis:
1. Flank pain
2. Chills
3. Fever
4. Vomiting
e. Nursing Care –
i. Monitor bladder frequency during recovery to institute preventive measures
ii. Culture and sensitivity of urine
iii. Antibiotics as ordered
iv. Antipyretics, Antispasmodics
v. Promote comfort, nutrition and hydration
vi. Assess vital signs
XXVII. Postpartum Hemorrhage:
a. Emergent situation
b. Blood loss > 500 mL following childbirth
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c. Leading cause of maternal mortality → approximately 11%

d. Early Hemorrhage – “immediate/primary”
i. Occurs in the first 24 hours postpartum
e. Late Hemorrhage – “secondary”
i. Occurs from 24 hours to 6 weeks after birth
ii. Most common cause is retained parts of the placenta
f. Causes:
i. Uterine atony –
1. Soft, boggy uterus usually above umbilicus and does not firm up with massage
ii. Vaginal lacerations
iii. Retained placenta fragments
iv. Cervix, labia, or perineum hematoma
v. Full bladder –
1. Uterus will be boggy and displaced to the right
vi. Unrepaired laceration
vii. Continuous trickle of blood
1. If present → **CHECK FUNDUS FIRST**
viii. Bleeding in spurts
ix. Bleeding in presence of firm uterus
g. Risk Factors –
i. High parity
ii. Dystocia
iii. Cesarean section
iv. Forceps or vacuum assisted
v. Over distended uterus
vi. Abruptio placentae / Placenta Previa (patient will bleed more)
vii. History of hemorrhage
viii. Infection
XXVIII. Developing Hematoma in Perineum:
a. Intense perineal pain
b. Swelling with blue/black discoloration on perineum
c. Pallor, tachycardia, and hypotension
d. Feeling of pressure in vagina, urethra, or bladder
e. Possible urinary retention of uterine displacement
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XXIX. Postpartum Blues:

a. AKA “baby blues”
b. Occurs in 50-70% of mothers
c. Typically occurs within a few days after birth → lasting 10 days – 2 weeks
i. More severe in primiparas
d. R/T rapid alteration in estrogen, progesterone, and prolactin levels after birth
e. Sign and Symptoms –
i. Mild depression with times of happier feelings
ii. Feeling overwhelmed
iii. Unable to cope
iv. Anxious, fatigued, irritable, and oversensitive
v. Tearfulness → may occur for no reason
XXX. Postpartum Depression:
a. Occurs in about 7- 30% of all women
b. Usually occurs around the 4th week
i. Can occur anytime in the 1st postpartum year
c. Signs and Symptoms –
i. Insomnia, appetite change
ii. Frequent crying, sadness, feels worthless
iii. Difficulty concentrating and making decisions, lack of interest in usual activities
iv. Irritable or hostile towards baby
v. Obsessive thoughts of inadequacy as a person/parent
XXXI. Postpartum Psychosis:
a. Occurs in 1-2 per 1,000 women
b. Develops within the first 3 months postpartum
c. Sign and Symptoms –
i. Agitation, confusion, insomnia
ii. Hyperactivity, poor judgment
iii. Hallucinations, delusions, mood lability
d. Treatment –
i. Hospitalization
ii. Sedatives, antipsychotic medications
iii. Psychotherapy
iv. Removal of infant