Complications of Labor

Complications of Pregnancy

ANTEPARTUM COMPLICATIONS
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 Placenta

previa is an obstetric complication that can occur in the second or third trimester of pregnancy.
It can some times occur in the latter part of the first trimester. It is a leading cause of antepartum hemorrhage (vaginal bleeding)

characterized

by the implantation of the placenta over or near the top of the cervix.

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Placenta

previa is classified according to the placement of the placenta:

Type I or low lying: The placenta encroaches the lower

segment of the uterus but does not infringe on the cervical os. Type II or marginal: The placenta touches, but does not cover, the top of the cervix. Type III or partial: The placenta partially covers the top of the cervix. Type IV or complete: The placenta completely covers the top of the cervix. This type of praevia often will not bleed until labour starts.

 Causes:
Risk

unknown

Factors

Multiparity Advancing maternal age Multiple gestation Previous cesarian birth Uterine incisions

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Signs and Symptoms

.bright red, painless vaginal bleeding .soft, nontender abdomen; relaxes between contractions, if present FHR stable and within normal limits

Medical Intervention
Immediate delivery of the fetus Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary. In cases of fetal distress, a Ceasarean section is indicated. Vaginal delivery.
There are two ways of doing this with a placenta previa: 1. The baby's head can be brought down to the placental site (if necessary with Willet's forceps or a vulsellum) and a weight attached to his scalp 2. A leg can be brought down and the baby's buttocks used to compress the placental site.

 Nursing

Interventions

Take and record vital signs. Assess bleeding, and maintain a perineal pad count is a primary intervention in patients with placenta previa. Observe for shock. Monitor FHR is also important. Enforce strict bed rest. Provide client and family teachings about the condition and give management options. Ensure an adequate blood supply to the mother and fetus, place the woman at bed rest in a side lying position. Anticipate the order for a sonogram to localize the placenta Prepare the patient for ambulation and discharge (may be within 48 hours of last bleeding episodes). Discuss the need to have transportation to the hospital available at all times. Instruct the patient to return to the hospital if bleeding recurs and to avoid intercourse until after the birth. Offer emotional support to facilitate the grieving process, if needed.

Abruptio

placenta

is the separation of the placental lining from the uterus of a female. it refers to the abnormal separation after 20 weeks of gestation and prior to birth.

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Abruptions are classified according to severity in the following manner:

Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta. Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus.

Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring.
Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.

Causes: unknown Risk factors

Maternal hypertension is a factor in 44% of all abruptions. Maternal trauma, such as motor vehicle accidents, assaults, falls, or nosocomial Drug use is a factor, particularly tobacco, alcohol, and cocaine. Short umbilical cord Prolonged rupture of membranes (>24 hours) Retroplacental fibromyoma Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk. Previous abruption: Women who have had an abruption in previous pregnancies are at greater risk. Multipara: Women who have given birth many times are at greater risk.

 Signs

and Symptoms

>contractions that don't stop >pain in the uterus >tenderness in the abdomen >vaginal bleeding (sometimes) >fetal distress >back pain

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Medical

Intervention

..Monitor the fundus. ..Give Rhogam if mother is Rh negative. ..Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother is in distress. ..Blood volume replacement. ..Blood plasma replacement ..Vaginal birth is usually preferred over caesarean section unless there is fetal distress.

 Nursing

1.Primarily, continue evaluate maternal and fetal physiologic status particularly. Vital signs Bleeding Electronic fetal and maternal monitoring tracings Signs of shockrapid pulse, pallor, cold and moist skin decrease in blood presure Decreasing uterine output 2. Never perform vaginal or rectal examinations or take any actions that would stimulate uterine activity. 3. Assess the need for immediate delivery. 4. If the client is in active labor and bleeding cannot be stopped with bed rest, emergency cesarean delivery may be indicated. 5. Provide bed rest in lateral position. 6. Insert a large gauge intravenous catheter into a large vein for fluid replacement. 7. Obtain a blood sample for fibrinogen levels. 8. Monitor the FHR. 9. Measure maternal vital signs every 5 to 15 minutes. 10. Administer oxygen to the mother via mask and prepare for cesarean section. 11. Address emotional and psychosocial needs.

Intervention

ECLAMPSIA AND PRE-ECLAMPSIA

Pre-eclampsia
is said to be present when hypertension arises in pregnancy (pregnancy-induced hypertension) in association with significant protein in the urine.

Causes
unclear Principal cause appears to be a substance or substances from the placenta causing endothelial dysfunction in the maternal blood vessels.

Signs

and Symptoms

Hypertension more than 140/90 Proteinuria 300mg in a 24 hour urine sample Edema on hands and face.

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Eclampsia

is a serious complication of pregnancy and is characterized by convulsions. Usually eclampsia occurs after the onset of pre-eclampsia though sometimes no pre-eclamptic symptoms are recognizable.
Cause: unknown

The majority of cases are heralded by pregnancyinduced hypertension and proteinuria but the only true sign of eclampsia is an eclamptic convulsion, of which there are four stages.
Premonitory stage This stage is usually missed unless constantly monitored, the woman rolls her eyes while her facial and hand muscles twitch slightly. Tonic stage After the premonitory stage the twitching turns into clenching. Sometimes the woman may bite her tongue as she clenches her teeth, while the arms and legs go rigid. The respiratory muscles also spasm, causing the woman to stop breathing. This stage continues for around 30 seconds.

Signs

and symptoms

Clonic stage The spasm stops but the muscles start to jerk violently. Frothy, slightly bloodied saliva appears on the lips and can sometimes be inhaled. After around two minutes the convulsions stop, leading into a coma, but some cases lead to heart failure.
Comatose stage The woman falls deeply unconscious, breathing noisily. This can last only a few minutes or may persist for hours.

 Medical

Intervention

Prenatal health supervision. Admission to maternal-fetal intensive care unit. Restriction of activities Administration of sedative drugs

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 Nursing

Intervention

Balanced diet high in protein Monitor vital signs and FHR Minimize external stimuli, promote rest and relaxation. Measure and record urine output, protein level, and specific gravity. Assess for edema especially on the face, arms, hands, legs, ankles and feet. Assess if there is presence of pulmonary edema. Weight the patient daily and assess deep tendon reflexes every four hours. Assess for the placental separation, headeache and visual disturbancess, epigastric pain and altered level of consciousness.

INTRAPARTUM COMPLICATIONS
PREMATURE RUPTURE OF MEMBRANES

Signs

and Symptoms Marked by amniotic fluid gushing from the vagina Maternal fever Fetal tachycardia Malodorous discharge may indicate infection

 Predisposing

factors include:

multiparity incompitent cervix maternal age greater than 35 years old low weight gain during pregnancy and cervical damagefrom cervical instrumentation Diagnosis can usually be confirmed with nitrazine paper, which turns dark blue in the presence of amniotic fluid.

 Medical

Intervention
broadbe given penicilin or sealant to

Prophylactic administration of spectrum antibiotics must quickly. Intravenous administration of ampicilin. Application of a fibrin-based ruptured membranes Sterile speculum examination Cervical cultures Ultrasonographic documentation Immediate delivery

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Nursing

Interventions

.Strict bed rest .Teach pt. how to read thermometer .Avoid digital examination .FHR monitoring .Maternal vital signs

Preterm

labor

(also known as preterm birth) is defined medically as childbirth occurring earlier than 37 completed weeks of gestation.
Cause:

unknown

 RISK

FACTORS

1.A woman's previous history of preterm birth, or pregnancies that ended in miscarriage. 2.Multiple pregnancies (twins, triplets, etc.) are at a higher risk for premature birth. Uterine or cervical abnormalities. 3.Certain chronic disease such as high blood pressure, kidney disease and diabetes. 4.Infections of the cervix, uterus or urinary tract. Certain STDs, Beta Strep. 5.Substance abuse of tobacco, alcohol and other drugs. Women who have tried to conceive for more than a year before getting pregnant are at a higher risk for premature birth. Women under 18 or over 35 are at a higher risk for premature birth.

6.Inadequate nutrition during pregnancy. 7.Antepartum hemorrhage 8.Pre-eclampsia 9.Stress 10.Periodontal disease increases the risk of preterm birth more than 4 times. As a matter of fact this is one of the most serious risk factors, that is completely preventable.

Signs

and Symptoms

1. Four or more uterine contractions in one hour, before 37 weeks' gestation. 2. A watery discharge from the vagina which may indicate premature rupture of the membranes surrounding the baby. 3. Pressure in the pelvis or the sensation that the baby has "dropped". 4. Menstrual cramps or abdominal pain.

5. Pain or rhythmic tightening in lower abdomen or back. 6.Vaginal spotting or bleeding.

There are two tactics that can be used to deal with a potential premature birth:

Medical Intervention

The first resort is usually complete bed rest. Proper nutrition and especially hydration are important. In a hospital setting, a drug-free IV drip may be used to try to stop premature labor simply by improving the mother's hydration. Administer anti-contraction medications (tocolytics), such as ritodrine, fenoterol, nifedipine and atosiban.

A.delay the arrival of birth as much as possible, or B. Prepare the prospectively premature fetus for arrival. Both of these tactics may be used simultaneously.

Nursing Intervention
Assess

the mother and fetus Tocolytic therapy .beta adrenergic agonist . MgSO4 .prostaglandin synthetase inhibitors .Steroids

 Placenta

Placenta

is a severe obstetric complication involving an abnormal attachment of the placenta to the myometrium (the middle layer of the uterine wall). occurs when the placenta extends into the muscle of the uterine wall and happens in around 17% of all cases. the worst form of the condition and occurring in 57% of cases, is when the placenta penetrates the entire uterine wall. This variant can lead to the placenta attaching to other organs such as the bladder.

accreta
increta

Placenta

percreta

CAUSES
PLACENTA

PREVIA PREVIOUS CESAREAN SECTION

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Signs and Symptoms

Placenta

fails to separate Profuse hemorrhage may result depending on the portion of placenta involved

Medical Intervention
Hysterectomy Immediate

delivery

Nursing Intervention
Strict

bed rest Monitor maternal vital signs Monitor fetal heart rate

Uterine

rupture

is a potentially catastrophic event during childbirth by which the integrity of the myometrial wall is breached. In an incomplete rupture the peritoneum is still intact. With a complete rupture the contents of the uterus may spill into the peritoneal cavity or the broad ligament.

Scar

from previous cesarean section Uterine surgeries such as myomectomy, hysterotomy and others. Gunshot wounds or car accidents with blunt trauma to the abdomen
Uterine

CAUSES

curettage
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Signs and Symptoms

Abdominal

pain Vaginal bleeding Nonreassurinf FHR pattern Palpitation of fetal parts under the skin Signs of hypovolemic shock

Medical Intervention
Emergency

exploratory laparotomy with cesarean delivery accompanied by fluid and blood transfusion are indicated. Depending on the nature of the rupture and the condition of the patient the uterus may be either repaired or needs to be removed (cesarean hysterectomy). If the client has signs of possible uterine rupture, vaginal delivery is generally attempted

Nursing Intervention
Monitor

maternal labor pattern closely for hypertonicity. Recognize signs of impending rupture, immediately notify the physician, and call for assistance. Monitor maternal blood pressure, pulse, respirations and FHR. Insert a urinary catheter for precise determinations of fluid balance. Obtain blood to assess possible acidosis. Administer oxygen and maintain a patent airway.

POSTPARTUM HEMORRHAGE
is blood loss of more than 500ml following the birth of the newborn. CAUSES uterine atony lacerations retained placental fragments Trauma from delivery Uterine atony

Signs and Symptoms

Leakage

or a gush of blood tinged amniotic fluid from the vagina. Fever Foul smelling vaginal discharge Uterine tenderness

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Pathophysiology
Delayed uterine atony or placental fragments prevent the uterus from contracting effectively. The uterus is unable to form an effective clot structure and bleeding continues.

Medical Management
Obstetric

ultrasonography Surgical obstetrics Blood transfusion Pharmacological support Hospitalization for diagnostic studies Induced labor

Nursing Management
Monitor

vital signs Avoid any vaginal douches, sexual intercourse and putting anything into the vagina. Sterile techniques during vaginal exam Avoid baths or hot tubs

SUBINVOLUTION
is delayed return of the enlarged uterus to normal size and function. CAUSES -retained placental fragments and membranes -endometritis or uterine fibroid tumor
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Signs and Symptoms

Prolonged

lochial discharge Irregular or excessive bleeding Larger than normal uterus Boggy uterus

Medical Management
Hospitalization Dilatation

and curettage Administer antibiotics

Nursing Intervention
prevent

excessive blood loss and resulting complications massage the uterus monitor BP & pulse rate every 5-15minutes administer IV infusion, oxytocin and blood transfusion needed administer medications and oxygen measure and record intake and output prepare for D&C

PUERPERAL INFECTION
is an infection developing in the birth structure after delivery CAUSES
poor sterile technique delivery with significant manipulation cesarean birth overgrowth of local flora Aerobic and anaerobic microorganism Prolonged labor

Signs and Symptoms

temperature

exceeding 38C or higher -localized vaginal, vulval and perineal infection -endometritis -parametritis -peritonitis

Medical Management
Antibiotic

therapy Pelvic examination CBC Urinalysis ultrasound

Nursing Intervention
promote

process inspect perineum twice daily evaluate for abdominal pain, fever, malaise, tachycardia and foul smelling lochia administer antibiotics

resolution of the infectious

MASTITIS
is the inflammation of the breast tissue that is usually caused by infection or by stasis of milk in the ducts. CAUSES
injury to the breast Staphylococcus aureus Group A beta-hemolytic Streptococcus Newborns mouth infected with pathogen Mothers hands

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Signs and Symptoms

elevated

temperature, chills, general aching, malaise and localized pain increased pulse rate engorgement, hardness and reddening of the breast nipple soreness and fissures swollen and tender axillary lymph nodes