Intrapartum

Complications
T Stone Godena, CNM, MSN
Spring, 2016

Common complications
Group B Strep
Chorioamnionitis
Dysfunctional Labor
Precipitous Labor
Cord Prolapse
Shoulder dystocia
Meconium
Amniotic Fluid embolism

What is Group B strep?

A type of Gram +
streptococcal bacteria (not
to be confused with strep
throat-group A strep) found
as normal flora on
intestinal, rectal and
vaginal and bladder mucus
membranes of many people

What is the prevalence?

GBS
(25-35%).

What are the consequences for the

mother?
Usually benign for the carrier.
What are the consequences for the
newborn?
Newborn immune system is
immature so it can cause
neonatal sepsis

How do we manage it?

GBS
All pregnant

women screened
between
35-37 weeks
gestation.

What happens if they are

Positive? GBS
Treatment begins with ROM or

labor:
5 million units Penicillin G IV
loading dose then 2.5 million
units Q 4 hours until birth. Goal is
>2 completed doses.
For PCN allergy, Clindamycin 900
mg IV Q 8 hours if bacteria is
sensitive

Why not treat in

pregnancy? GBS
If treated in pregnancy,
about 65% of the time
the bacteria will
recolonize prior to labor
(since it is a normal part
of the persons flora)

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 if no screening
was
Treatdone?
based on risk factors:
Labor <37 weeks gestation (with
or without ruptured membranes).
Term with membranes ruptured
longer than 18 hours.
Unexplained fever in labor.
Previous baby with GBS infection.
Bladder or kidney infection in
pregnancy caused by the GBS
bacteria.

What is
An infection of the membranes
chorioamnionitis?

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

What are
Signs/Symptoms?
Maternal fever (>100.4 o
F)
Maternal/fetal tachycardia
Foul smelling amniotic
fluid
Uterine tenderness

How do we diagnose it?

Diagnosis per signs

and symptoms or
blood culture

How do we treat it?

IV antibiotics until birth
Acetominophen for relief of
tachycardia
Expedite birth
Common antibiotics
Ampicillin +Gentamycin +
Clindamycin

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 2 nd 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

Categories of dysfunctional
labor
Category
Nullipara
Multipara
Prolonged latent phase

> 20 hrs

> 14 hrs

Protracted dilatation

< 1.2 cm/hr

< 1.5 cm/hr

Arrest of dilatation*

> 2 hrs without

change

> 2 hrs without

change

Protracted descent

< 1 cm/hr

< 2 cm/hr

Arrest of descent*

> 2 hrs without

descent

> 1 hour without

descent

Prolonged second stage

without (with) epidural

>2 hr(>3 hr)

>1 hr (>2 hr)

* With documentation of >200

adequate contractions
Montivideo units
=
(MVU) per 10
minutes x 2
hours
A Po labor > 30 hrs associated with risk C/S and NICU admissions

Proposal for change

Both American College of Obstetrics and
Gynecology (ACOG) and the Consortium on
Safe Labor (CSL)have proposed extending the
minimum period before diagnosing active
phase arrest.
The CSL defines 6 hours as the 95th percentile
of time to go from 4 cm to 5 cm dilation, with
the active phase defined as beginning at 6 cm
(instead of 4 cm). ACOG has stated that
extending the time from 2 to 4 hours with
oxytocin augmentation appears effective for
allowing adequate time for cervical change
without increasing risk to mother or fetus.

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 FOR HYPO Complete assessment of the 5 Ps.

TONIC
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

Persistent Occiput
Posterior

Common cause of protracted

dilatation or protracted descent
disorders.
Nursing interventions:

knee chest position

-squats
-lunges
-pelvic rocking
-rolling side to side (Rebozo)

Inadequate expulsive
efforts
Causes: exhaustion, dense anesthesia
Risk to mother: C/Section
Risk to fetus: hypoxia, asphyxia

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.

Active phase dysfunction

Slow progress can be enhanced with position
change, hydration, reduction of anxiety,
encouragement
Augmentation: Pitocin or amniotomy
Documenting adequacy of Ucs (IUPC) is
important
Experimental: Low dose blockers when
abnormal contraction patterns have not
responded to Pitocin

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.

Name that complication

Definition Cord Prolapse

Passage of the umbilical cord through
cervix prior to birth of the baby
resulting in the presenting part
compressing the cord preventing oxygen
transfer to the fetus. Risk of hypoxia, CNS
damage, death
Types of prolapse:
May be occult (alongside the presenting
part) neither visible nor
palpable.
Or may be overt (visible or palpable).
cord

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

Management of Cord
Call for help.
prolapse

Have assistant notify obstetrician, assess

FHTs, O2 8-10 L/min., insert IV or IVF
Move fetal presenting part off cord
Knee-chest, trendelenberg or side-lying
with hand manually elevating presenting
part
If cord protruding from vagina, cover with
sterile, moist towel
Prepare for immediate birth (C/S)
Administer tocolytic if ordered.

Name this complication

What is shoulder
dystocia?
Failure of the fetal shoulders to deliver after the
head is born.
How does it happen?
It occurs because of a relative size or positional
discrepancy between the fetal and pelvic bony
dimensions.
How often does it happen?
Incidence: 0.3% in infants weighing 2500

4000 grams. 5-7% in infants weighing 4000

4500 grams Still time, they arent
predictable

Who is at risk for

shoulder dystocia?

Women with h/o shoulder dystocia

Macrosomic infants
Diabetes/Impaired carbohydrate
metabolism
Obesity/Excessive weight gain in
pregnancy
Post-term pregnancies
Prolonged 2nd stage
Precipitous 2nd stage
Instrumental delivery

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

Hyperflexion of maternal thighs toward the abdomen. It raises the

Symphysis about 9 mm.. Resolves almost of shoulder dystocias
without further maneuvers. May require 2 people.

Suprapubic pressure

firm or rocking 45o downward pressure with palm or fist

above the pubic bone to dislodge the fetal shoulder. May be
combined with McRoberts.

Hands and Knees

Rescuscitation

Name this complication

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

Risks of meconium in
amniotic fluid

Decreases antibiotic properties of amniotic fluid-risk chorioamnionitis

Meconium staining causes a chemical irritation of
fetal skin causing desquamation
Meconium Aspiration Syndrome (MAS)

Meconium Aspiration Syndrome

Meconium aspiration can occur in utero
or with the babys first breath.
Meconium Aspiration Syndrome (MAS)
causes respiratory distress: by
deactivating surfactant, mechanical
blockage of airway, chemical
pneumonitis, alveolar collapse and
necrosis eventually leading to a bacterial
infection. Some develop persistent
pulmonary hypertension
~1-10% of babies with MAS die.
Surviving babies have a risk of asthma,
pneumonia, brain damage from hypoxia,
persistent pulmonary hypertension.

Management per AAP

1) Pediatrician present for birth.
2) Newborn transferred immediately to warmer for
intubation and deep suctioning if meconium visualized
below the cords. DO NOT dry or stimulate the newborn.

3) If baby cries or breathes vigorously immediately after

birth, routine caredry, stimulate, put skin-to-skin.
4) Assess for immediate or delayed respiratory distress,
cyanosis.

Amniotic Fluid embolism

Not completely understood; thought to be more
like anaphylaxis than embolism. Postulated:
Amniotic fluid or fetal cells enter maternal
circulation
Risk factors: multiparity, abruption, pitocin use,
polyhydramnios, fetal demise, meconium-stained
amniotic fluid.
Usually occurs intrapartum. Mortality rate up to
85% maternal, 50% fetal.

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?