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Labor and Birth

Complications/ Variations
During Postpartum
February 10th, 2005
Maria Rubolino

Complications

Some anticipated
Higher perinatal mortality and
morbidity
Some women feel a sense of failure

Dystocia

Long, difficult, or abnormal labor


Can be caused by:
Dysfunctional labor
Alterations in the pelvic structure
Maternal position
Fetal causes
Psychologic responses

Dysfunctional Labor

Abnormal UCs, that prevent the normal


progression of cervical dilation,
effacement, or descent
Higher with AMA

Overweight
Uterine abnormalities
CPD
Malpresentation
Hyperstimulation
Maternal fatigue
Anesthesia

Hypertonic Uterine Dysfunction

Typically first time mom


Having painful and frequent UCs that
are not causing dilatation
Maternal exhaustion
Loss of control
Tx: Therapeutic rest

Hypotonic Uterine Dysfunction

Woman makes normal progress


Once active phase begins, UCs
become weak and inefficient or stop
contracting
CPD
Malpresentation

Bearing-Down Efforts

Anesthesia is given and blocks the


effectiveness of pushing
Fatigue, inadequate hydration,
maternal position can affect this

Pelvic Dystocia

Diameter of the pelvic inlet/outlet is


contracted
Due to:
-

Dystocia Related to the Fetus

Due to anomalies, fetal size,


malpresentation, multiples
Typically an assisted delivery

CPD

4000 gms or more


Cannot fit through the pelvis
Associated with certain conditions:

Malposition

Head positioned incorrectly in the


pelvis
ROP/LOP
Typically will have a longer second
stage
More painful

Malpresentation

Something other than a head


descending in the pelvis first
Face/Brow presentation
Shoulder presentation
Breech 3-4% of all births
Types:
Frank
Complete
Incomplete

Types of Breech

Multiple Gestation

Twin birth rate has increased


Fertility enhancing drugs, AMA
Higher incidence of complications
of all twin pregnancies have both
fetuses in vertex position
Increased risk for mother

Precipitous Labor

Lasts less than 3 hours


Higher rates among mulitparous
women and 40-49 years old
Complications:
Uterine rupture
Lacerations
Fetal hypoxia

External Version

Turn the fetus to vertex position


Typically before 37 weeks
Done inpatient setting
NST done prior to exam
IV
Relaxants
Informed consent
Done with UTZ
NST after procedure

Internal Version

Converting the presentation of the


fetus in utero
Most often used for 2nd twin
Must be completely dilated

TOL

Done if questionable size/shape of


the pelvis
Previous C/S
Evaluated often

Induction of Labor

Use of mechanical or chemical


initiation of UCs prior to
spontaneously occurring
Should be used when the risk of birth to
mother or fetus is less than risk of
continuing pregnancy
Inductions increasing with increased
litigation

Bishops Score

Can be used to evaluate how


inducible one is and how they should
respond to labor

Augmentation

Progress of labor has slowed or


needs to be speeded up due to
maternal/fetal problems
Medications
Mechanical

Cervical Ripening

Ripen - soften and thin the cervix


Prostaglandin gels
Hydroscopic Dilators - seaweed
substance absorbs fluid from
surrounding tissue and then enlarges
Synthetic prostaglandin tablets
Vaginal insert
Needs monitoring
IV/Saline lock

AROM

Cervix should be favorable


Labor typically begins within 12 hours
from rupture
Used in combination with meds
Head should be well engaged
Amnihook needed for procedure
Color, amount, odor, consistency is
assessed
FHTs assessed

PROM

Rupture of amniotic sac at least 1


hour before the onset of labor
Typically begin labor within 12 hours

PPROM

Membranes rupture before 37 weeks


gestation
25% of all cases of preterm labor
Usually infection will cause this
Complication: chorioamnionitis
Fetal complications: pneumonia,
sepsis and meningitis

Pitocin

Hormone produced by the posterior pituitary gland


Induce or augment labor
Fetal monitoring important
Can cause hyperstimulation of UCs
Every hospital has a protocol
Contraindications:

Nonreassuring FHTs
Unable to trace FHTs
Previa
Prior classical incision/Prior cesarean section
Active herpes
Prolapsed cord
Malpresentation

Shoulder Dystocia

Emergency
Fetus can experience birth injuries
Mother can experience blood loss
Head is born but anterior shoulder
cannot pass under the pubic arch
Head emerges, it retracts against the
perineum and external rotation does
not occur
Nursing care McRoberts maneuver

Prolapsed Umbilical Cord

Cord lies below the presenting part of the


fetus
May be hidden
May see after ROM
1 in 400 births
Medical emergency for C/S unless fully
dilated may attempt vaginal delivery with
mechanical assistance
Relieve pressure on the cord by:
Trendelenburg
Knee-Chest

Rupture of the Uterus

Rare but medical emergency


Typically separation of previous
uterine scar, uterine trauma, uterine
anomaly
During labor may be due to:
intervention with medication inducing
drugs, malpresentation, multiples,
versions
More often in multiparous

Bleeding is usually internal


Complete vs. incomplete
Signs/Symptoms
Maternal

Vomiting
Faintness
Increased abdominal pressure/tenderness
Hypotonic UCs

Fetus
May show decelerations
Decreased variability
Increased or decreased FHR

Amniotic Fluid Embolism

When amniotic fluid contains


particles of debris enters the
maternal circulation and obstructs
pulmonary vessels, causing
respiratory distress and circulatory
collapse
More damaging if meconium present
Typically ventilated

Forceps Assisted Birth

Mechanical help in delivery of the


fetus
Two curved blades help in assisting
with the birth
Use has been decreasing
Indications :
Fetal distress
Arrest of rotation
Deliver head in breech presentation

Outlet forceps - fetal scalp is visible


on the perineum without separating
labia
Low forceps head is at +2 station
Mid forceps fetal head is engaged
no higher than station 0, but above
+2 station

Simpson forceps typically used


Kjellands forceps rotation of the
head
Piper forceps designed to facilitate
delivery of the head after a breech
delivery
Complications: transient bruising
Laceration on the head or cervix

Vacuum Assisted Birth

Attachment of vacuum to fetal head using


negative pressure
Use declining
Vacuum applied by MD
Cup is placed over posterior fontanelle
Pop-offs occur if excessive force used
Some types of vacuums RN will control
amount of suction
Kiwi vacuum operated independently by
MD

Vacuum pressure is lowered in between


UCs
Maternal risks:
Perineal lacs
Vaginal lacs
Cervical lacs

Risks to fetus:
Cephalhematoma
Scalp lacerations
Subderal Hematoma

Cesarean Section

Surgical birth of a fetus through a


transabdominal incision of the uterus
Planned or emergency
Preserve the life of the fetus
C/S have increased to more than
20%
Women 35 years of age and older
have a C/S rate that is almost 30%

Some women want a trial of labor


Nurse can affect the rates
Indications:

CPD
Non reassuring FHTs
Placental location
Malpresentation
Cord prolapse
HSV
Preeclamsia/Eclampsia
Multiples
Hypertensive disorders

Types of C/S

C/S

Risks:

Blood loss
Infection
Uterine rupture
Aspiration
Pulmonary embolism
Wound Infection
Thrombophlebitis
Bowel/Bladder injuries
Complications with anesthesia

Anesthesia

Spinal
Epidural
General
Local

VBAC

Allowing TOL
Low transverse incision
Emergency resources should be
available
Physician should be readily available
(within 30 minutes)

Preoperative Care

Hospital protocol
Shave low abdomen
Jewelry removed
NST
Monitoring maternal VS
IV - bolus
Labs
Consent
Antibiotics
Foley
Antiemetics

Postoperative Care

Vital Signs

Postpartum Period

PP Hemorrhage

Loss of more than 500 ccs of blood


during the first 24 hours after a
vaginal delivery or 1000 ccs after
C/S birth
Can occur with little warning
10% change in Hct
Blood loss can be underestimated by
as much as 50%

Cause uterine atony, retained


placental fragments, placenta
accreta, uterine rupture, coagulation
problems
Risk factors: Prolonged labor with
prolonged use of labor inducing
meds, overdistention of the uterus,
previous PPH, fibroids, DIC

Uterine Atony

Accounts for 90% of all PPH


Boggy
Non-contracted uterus
Treatment:
Massaging fundus
Replace fluids
Medications

Lacerations

Cervix, vagina, perineum


If bleeding continues even with
uterus remaining firm and contracted
Extreme vascularity of the perineum
typically cause this

Hematomas

Collection of blood in the connective


tissue
Very tender/painful
Associated more often with assisted
deliveries

Retained Placental Fragments

Typically placenta separates after


birth of infant within 30 minutes
after birth
Partial separation of a normal
placenta
Common in preterm births
Treatment: manual separation or
D&C

Prevention of PPH

Massage relaxed UT until firm


Notify MD if heaving bleeding
persists or restarts
Give medications
Monitor uterus tone, location, height
Monitor VS

Treatment of PPH

IV
PRBCs
Medications: Pitocin, methergine,
hemabate, cytotec, calcium
gluconate
Catheter
O2

Uterine Inversion

Medical emergency
Replacement of UT into pelvic cavity
Manual replacement is successful
75% of women
Antibiotics

Subinvolution

Delay in return to normal size and


function of uterus characterized by
large, boggy uterus
Prolonged lochia-sometimes heavy

Hypovolemic Shock

Emergency
Perfusion to body organs may
become compromised resulting in
death

Idiopathic Thrombocytopenia
Purpura

Antiplatelet antibodies decreased the


lifespan of the platelets
Increased bleeding time
Control of platelets
Splenectomy done if ITP does not
respond to other management

Von Willebrands Disease

Type of hemophilia
Factor VIII deficiency and abnormal
platelet function
Factor VIII increases during
pregnancy

DIC

Form of clotting
Large amount of clots and platelets
Total bleeding from all cites can occur
Causes:

Abruptio placenta
Amniotic embolism
Fetal demise (in utero at least 6 weeks)
Severe preeclampsia
Septic infection

DVT

Can extend from the foot to femoral


region
1 in 1000 to 2000
Early ambulation
Risk factors:

Bedrest
Smoking
HTN
Obesity
Varicose veins

Doppler study to diagnose


Tx: anticoagulant therapy, bedrest

PP Infection/Puerperal Sepsis

Any genital infection occurring within


28 days of birth
Fever typically seen
6% of births in US
Greater likelihood after prolonged
ROM, frequent VEs, C/S, IC after
ROM,poor nutrition

Endometritis

Localized infection of the lining of the


UT
Typically beginning at the placental
site
48-72 hours after delivery
May extend to other areas including
fallopian tubes
Fever, chills, nausea, fatigue, PP

Wound Infections

C/S, episiotomy, laceration sites


Erythema, edema, odor, warmth

Mastitis

Breast infection
Typically develops when breast
feeding
Develops after milk supply has been
established
Bacteria enters through nipple
fissures
Chills, fever, erythema, tenderness,
engorgement, usually unilateral

Prevention: hygiene, hand washing,


empty breasts completely
TX: antibiotics, I&D (if severe), heat
and cold packs, massage, expression
of milk
Organism: Staph aureus