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Week 10 Class 15 Intrapartum Complications With Answers
Week 10 Class 15 Intrapartum Complications With Answers
Common complications
Group B Strep
Chorioamnionitis
Dysfunctional Labor
Precipitous Labor
Cord Prolapse
Shoulder dystocia
Meconium
Amniotic Fluid embolism
How do we screen?
A Q tip is inserted into the lower 1/3 of
the vagina, swiped down the
perineum then into the anus. The Qtip
contents are then planted into a
culture. Results are positive or
negative. If positive, antibiotic
sensitivities are recorded.
What is chorioamnionitis?
An infection of the membranes of the
placenta and amniotic fluid caused by
bacteria ascending from the maternal
urogenital tract (anus, vagina). Generally
polymicrobial (not just one type of
bacteria).
What is the Incidence?
Occurs 2-4% of the time
Who is at risk?
Women with Premature &/or
prolonged rupture of membranes,
multiple vaginal exams,
internal monitoring,
immunocompromised state,
STIs
Complications chorioamnionitis
Maternal
(2-3 x risk
Cesarean Section )
PP endometritis
Wound infection
PP hemorrhage
Pelvic/leg blood
clots
Fetal/Neonatal
Meningitis
Intraventricular
hemorrhage
Sepsis
Cerebral Palsy (4 x
risk over random
population)
Death
Dysfunctional labor
Other names: Arrest of labor, arrest of
descent, failure to progress, labor dystocia,
protracted labor, obstructed labor.
May be HYPO or HYPERtonic contractions
or inadequate expulsive efforts.
HYPERtonic occurs early in latent phase
HYPOtonic may cause protraction or arrest
disorders and can occur during latent
phase, active phase or the second stage of
labor
Inadequate expulsive efforts is in 2nd stage
Associated factors
Extremes of reproductive age
Soft tissue abnormalities
Pelvic abnormality
Short maternal stature, esp. if BMI
Large baby
Exhausted, fearful or dehydrated
mother
Malpresentation/malposition
Ill-timed anesthesia/analgesia
Nullipara
Multipara
> 20 hrs
> 14 hrs
Protracted dilatation
Arrest of dilatation*
Protracted descent
< 1 cm/hr
< 2 cm/hr
Arrest of descent*
* With documentation of
adequate contractions =
>200 Montivideo
units (MVU) per 10
minutes x 2 hours
A Po labor > 30 hrs associated with risk C/S and NICU admissions
HYPERtonic dysfunction
Usually < 4 cm.
Etiology unkown
Pain out of proportion to stage of labor
Contractions may be frequent but not
coordinated
Risks to mother: exhaustion, C/S
Risks to fetus, meconium passage,
possible hypoxia
Treatment HYPER
Augmentation if co-morbidity requires
hastening delivery
Therapeutic rest preferable:
Morphine sulfate given. Patient
sleeps and either awakens in active
labor or contractions stop.
HYPOtonic
Causes: Remember the 5 Ps
Risks to mother: Infection (if ROM),
exhaustion, C/Section, death
(amniotic fluid embolism)
Risks to fetus: infection, hypoxia,
asyphxia (permanent neurological
damage or death)
Treatment
Complete assessment of the 5 Ps.
Determine if there is cephalopelvic
disproportion(CPD) r/o Pelvic
contractures, young teens, h/o MVAs
If CPD ruled out: augmentation
Movement, hydration, hydrotherapy,
oxytocin. Fully address pain relief
needs
Nursing interventions:
knee chest position
-squats
-lunges
-pelvic rocking
-rolling side to side (Rebozo)
Treatment
Labor down
Change position
Decrease level of anesthesia
Assisted vaginal birth if fetal head low
enough
C/Section
How do we Manage
dysfunctional labor?
Prolonged Latent Phase (PLP)
85% can be resolved with therapeutic
rest (same protocol as for HYPERtonic
uterine dysfunction.
Precipitous Labor
Labor lasting <3 hours.
What are risks of precipitous labor:
Unplanned site of birth
Sometimes more painful & harder to cope
risk for Postpartum hemorrhage
Babies are usually fine, though there is a small
risk of delivering in an unclean area or facial
bruising
risk for perineal/cervical/vaginal lacerations
Small risk for shoulder dystocia
Nursing management
If woman arrives in advanced labor,
especially a multipara:
Observe perineum, Prepare for rapid
delivery, Notify provider stat, stay
calm and calm mother.
Incidence1/300 births.
Predisposing factors
Prematurity
Malpresentation/Malposition
Multiple gestation
Polyhydramnios
Unusually long umbilical cord
Low lying placenta
AROM with high presenting part
Attempted rotation of posterior head
Grand multiparity
Diagnosis
Usually occurs when membranes
rupture
Nursing management at membrane
rupture= Auscultate fetal heart or
visually appreciate it on EFM
If bradycardia, prolonged or variable
decelerations, observe for cord outside
the vagina or place fingers in the
vagina
Mechanics
During the fetal heads extension during delivery,
and prior to expulsion, the fetal shoulders need to
rotate within the bony pelvis to arrive in the most
accommodating dimension of the pelvis: the
oblique diameter.
If either the fetal shoulders are too large or the
maternal pelvis is too narrow to permit this
rotation to the oblique, a persistent anteroposterior
orientation of the fetal shoulders may result in the
anterior shoulder being obstructed behind the
symphysis pubis, impeding delivery and leading to
shoulder dystocia.
Nursing Management
Identify risk factors
Have extra staff and foot stool
Break the bed
Recognize signs/symptoms: turtle
sign, normal traction not delivering
shoulders
Prepare to respond rapidly
Call time out loud every 30 seconds
after birth of head until the body is
expelled.
Management cont.
Perform maneuvers as directed:
McRoberts
Suprapubic pressure
Hands and Knees
Be prepared to resuscitate
McRoberts maneuver
Suprapubic pressure
Rescuscitation
What is Meconium?
Sterile, viscous, dark-green substance
composed of intestinal epithelial cells, lanugo,
mucus, and intestinal secretions eg, bile (fetal
stool).
Who is at risk for passage before or during
birth?
Placental insufficiency, PEC,
oligohydramnios, maternal drug abuse,
especially tobacco and cocaine. Mature fetal
GI tract (postdates) and fetuses who were
breech for extended time.
Characteristics of Meconium
May occur remote from labor,during
labor or with first breath.
May be thin, thick, particulate, pea
soup
May or may not be associated with
fetal intolerance of labor
May or may not be aspirated by
fetus/newborn
Nursing Management
Identify risk factors
Recognize S/S: sudden chest pain, Acute
dyspnea, hypotension, cyanaosis,
tachycardia, seizure like activity, followed
by cardiac arrest. DIC follows shortly
(bleeding from orifices or IV site).
Call for help. Notify attending
Management cont.
Oxygen via face mask at 8-10 L/min.
Position woman on her side with pelvis tilted
at 30 degree angle to displace uterus
Administer IV fluids & blood products as
prescribed.
Insert foley catheter and measure I&O.
Monitor maternal and fetal status.
Prepare for Cesarean if undelivered
CPR: Assist with intubation and mechanical
ventilation prn.
Any questions?