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Chapter 32
Labor and Birth Complications
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Learning Objectives
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Differentiate between preterm birth and low
birth weight.
Describe the criteria for very preterm, early
preterm, late preterm, and the implications of
each.
Discuss major risk factors associated with
preterm labor.
Analyze current interventions to prevent
spontaneous preterm birth.
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Learning Objectives (Cont.)
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Discuss the use of tocolytics and antenatal
glucocorticoids for management of preterm
labor.
Design a nursing care plan for women with
preterm premature rupture of membranes
(preterm PROM).
Explain the care of a woman with postterm
pregnancy.
Explain the challenge of caring for obese
women during labor and birth.
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Learning Objectives (Cont.)
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Summarize the nursing care for a trial of
labor, the induction and augmentation of
labor, forceps- and vacuum-assisted birth,
cesarean birth, and vaginal birth after a
cesarean birth (VBAC).
Discuss obstetric emergencies and their
appropriate management.
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Preterm Labor and Birth
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Preterm labor and birth
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Preterm labor (PTL): cervical changes and uterine
contractions occurring at 20 to 37 weeks of
pregnancy
Preterm birth: birth that occurs before the
completion of 37 weeks (<37 0/7 weeks of
gestation)
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Preterm Labor and Birth (Cont.)
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Preterm birth versus low birth weight
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Preterm birth or prematurity: length of gestation
regardless of birth weight
• More dangerous than birth weight alone because less
time in the uterus correlates with immaturity of body
systems
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Low birth weight: ≤2500 grams at birth
• Many potential causes, including preterm
• Intrauterine growth restriction (IUGR)
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Preterm Labor and Birth (Cont.)
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Spontaneous versus indicated preterm birth
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Spontaneous: 75% of preterm births
Indicated: 25% of preterm births
Causes of spontaneous preterm labor and
birth
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Multifactorial
Infection is the only definitive factor
Placental causes
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Preterm Labor and Birth (Cont.)
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Predicting spontaneous preterm labor and
birth
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Risk factors
Cervical length
• Not predictive of PTL or birth
• But cervical length >30 mm unlikely to give birth
prematurely
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Fetal Fibronectin (fFN)Test
• fFN is a glycoprotein “glue” found in plasma and
produced during fetal life.
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PTL Care Management
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Assessment
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Interventions
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Patient teaching
Prevention
Early recognition and
diagnosis
Lifestyle
modifications
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Activity restriction
Restriction of sexual
activity
Home care
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PTL Care Management (Cont.)
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Suppression of uterine activity
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Promotion of fetal lung maturity
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Tocolytic medications
Antenatal glucocorticoids: significantly reduce the
incidence of respiratory distress syndrome,
intraventricular hemorrhage, necrotizing
enterocolitis, and death in neonates
Management of inevitable preterm birth
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Fetal and early neonatal loss
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Premature Rupture of Membranes
(PROM)
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PROM: Spontaneous rupture of amniotic sac
and leakage of fluid prior to the onset of labor
at any gestational age
PPROM: membranes rupture before 37 0/7
weeks of gestation
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Responsible for 10% of all preterm births
Often preceded by infection
• Chorioamnionitis
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PROM and PPROM Care
Management
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Determined individually for each woman
Full-term birth is the best option.
PPROM <32 weeks is managed expectantly
and conservatively.
Vigilance for signs of infections
Fetal assessment
Antenatal glucocorticoids
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Chorioamnionitis
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Bacterial infection of the amniotic cavity
Major cause of complications for mothers and
newborns at any gestational age
Diagnosed by the clinical findings of maternal
fever, maternal and fetal tachycardia, uterine
tenderness, and foul odor of amniotic fluid
Neonatal risks
Treatment
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Postterm Pregnancy, Labor, and
Birth
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Postterm pregnancy (postdates) pregnancy
≥42 weeks of gestation
Maternal risks
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Dysfunctional labor and birth canal trauma
Labor and birth interventions more likely
Woman may experience fatigue and psychologic
reactions as estimated date of birth passes.
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Postterm Pregnancy, Labor,
and Birth (Cont.)
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Fetal risks
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Abnormal fetal growth (macrosomia)
Prolonged labor
Shoulder dystocia
Birth trauma
Compromising effects on fetus of “aging” placenta
Postmaturity syndrome
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Postterm Pregnancy, Labor,
and Birth (Cont.)
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Care management
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Controversial
Perinatal morbidity and mortality increase greatly
after 42 weeks of gestation.
More frequent fetal assessment, testing
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Case Study
Your client is a G2 P1001 at 42 weeks
gestation. Her biophysical profile (BPP) exam
was 4/10.
• What does this mean about the health of her
fetus?
• Given her gestational age, what are some of
the potential causes of this condition?
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Case Study (Cont.)
Her cervical exam reveals cervix is closed/long/
-3/firm/posterior
• What is her Bishop’s score?
• Given this score, what type of induction orders might
the nurse anticipate?
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Case Study (Cont.)
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What potential newborn complications might
the nurse expect at birth?
Describe some typical features of the
postdates newborn.
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Dysfunctional Labor (Dystocia):
Overview
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Long, difficult, or abnormal labor
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Most common indication for c-birth
Five factors affect labor
• The powers
• The passage
• The passenger
• Maternal position
• Psychologic responses
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Dysfunctional Labor (Dystocia):
Causes
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Abnormal uterine activity
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Hypertonic uterine dysfunction
• Therapeutic rest
Hypotonic uterine dysfunction
• Initially makes normal progress into the active phase of
first-stage labor but then the contractions become weak
and inefficient or stop altogether
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Dysfunctional Labor (Dystocia):
Causes (Cont.)
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Secondary powers
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Abnormal labor patterns
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Problems with bearing-down efforts
Friedman’s classification of “normal” labor patterns
Updated, evidence-based awareness of “normal”
labor
Precipitous labor
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Labor that lasts less than 3 hours from the onset
of contractions to the time of birth
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Dysfunctional Labor (Dystocia):
Causes (Cont.)
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Alterations in pelvic structure
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Pelvic dystocia
• Contractures of pelvic diameters that reduce the capacity
of the bony pelvis, inlet, midpelvis, or outlet
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Soft-tissue dystocia
• Results from obstruction of the birth passage by an
anatomic abnormality other than that of bony pelvis
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Dysfunctional Labor (Dystocia):
Causes (Cont.)
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Fetal causes
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Anomalies
Cephalopelvic disproportion (CPD), also called
fetopelvic disproportion (FPD)
Malposition
Malpresentation
Multifetal pregnancy
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Dysfunctional Labor (Dystocia):
Causes (Cont.)
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Position of the woman
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Maternal position alters relationship between
uterine contractions, fetus, and mother’s pelvis
Psychologic responses
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Hormones and neurotransmitters released in
response to stress can cause dystocia
Sources of stress and anxiety vary
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Obesity
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Serious problem in affluent nations
BMI of 30 kg/m2 or greater
BMI of 40 kg/m2 or greater extremely obese
Complications
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Venous thromboembolism
Cesarean birth
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Obstetric Procedures:
Version
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External cephalic version (ECV)
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An attempt to turn the fetus from a breech or shoulder
presentation to a vertex presentation for birth
Ultrasound scanning used during procedure
NST and informed consent before procedure
Contraindications to ECV
Internal version
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Rarely used; safety questionable
Used most often in twin gestations to deliver the second
fetus
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Obstetric Procedures:
Version (Cont.)
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Obstetric Procedures:
Induction of Labor
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The chemical or mechanical initiation of
uterine contractions before their spontaneous
onset for the purpose of bringing about birth
Labor may be induced either electively or for
indicated reasons.
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Obstetric Procedures:
Induction of Labor (Cont.)
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Elective induction of labor
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Labor is initiated without a medical indication.
Many are for the convenience of the woman or her
primary health care provider.
Risks:
• Increased rates of cesarean birth
• Increased neonatal morbidity
• Increased cost
Elective induction of labor should not be
initiated until the woman reaches 39
completed weeks of gestation.
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Obstetric Procedures:
Induction of Labor (Cont.)
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Bishop’s score
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A rating system used to evaluate inducibility or
cervical ripeness
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Obstetric Procedures:
Induction of Labor (Cont.)
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Cervical ripening methods
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Chemical agents
Mechanical and physical methods
Alternative methods
Amniotomy
Oxytocin
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Hormone normally produced by the posterior pituitary gland,
which stimulates uterine contractions and aids in milk letdown
Synthetic oxytocin (Pitocin) may be used either to induce
labor or to augment labor that is progressing slowly because
of inadequate uterine contractions.
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Obstetric Procedures:
Augmentation of Labor
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Stimulation of uterine contractions after labor
has started spontaneously and progress is
unsatisfactory
Common augmentation methods include
oxytocin infusion and amniotomy.
Active management
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Obstetric Procedures:
Operative Vaginal Birth
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Operative vaginal
births are performed
using either forceps
or a vacuum
extractor
Forceps-assisted
birth
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Obstetric Procedures:
Operative Vaginal Birth (Cont.)
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Operative vaginal
births are performed
using either forceps
or a vacuum
extractor
Vacuum-assisted
birth
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Obstetric Procedures:
Cesarean Birth Overview
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Birth of a fetus through a transabdominal
incision of the uterus to preserve the wellbeing of the mother and her fetus
Cesarean birth rate in the United States has
been over 32% since the early 2000s
VBAC = Vaginal birth after cesarean
TOLAC = Trial of labor after cesarean
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Obstetric Procedures:
Cesarean Birth (Cont.)
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Elective cesarean birth
Scheduled cesarean birth
Unplanned cesarean birth
Forced cesarean birth
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Obstetric Procedures:
Cesarean Birth (Cont.)
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Surgical techniques
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Obstetric Procedures:
Cesarean Birth (Cont.)
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Complications and risks
Anesthesia
Prenatal preparation
Preoperative care
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Obstetric Procedures:
Cesarean Birth (Cont.)
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Intraoperative care
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Obstetric Procedures:
Cesarean Birth (Cont.)
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Immediate
postoperative care
Postoperative
postpartum care
Nursing
interventions
Trial of labor
Vaginal birth after
cesarean
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Obstetric Emergencies
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Meconium-stained amniotic fluid
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Indicates fetus has passed stool prior to birth
Dark green
Possible causes
• Normal physiologic function of maturity
• Breech presentation
• Hypoxia-induced peristalsis
• Umbilical cord compression
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Obstetric Emergencies (Cont.)
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Shoulder dystocia
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Head is born, but anterior shoulder cannot pass
under pubic arch
Newborn more likely to experience birth injuries
related to asphyxia, brachial plexus damage, and
fracture
Mother’s primary risk stems from excessive blood
loss from uterine atony or rupture, lacerations,
extension of episiotomy, or endometritis.
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Obstetric Emergencies (Cont.)
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Obstetric Emergencies (Cont.)
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Prolapsed umbilical
cord
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Occurs when cord lies
below the presenting part
of the fetus
Contributing factors
include:
• Long cord (longer than
100 cm)
• Malpresentation
(breech)
• Transverse lie
• Unengaged presenting
part
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Obstetric Emergencies (Cont.)
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Obstetric Emergencies (Cont.)
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Rupture of the uterus
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Rare, serious obstetric injury; occurs in 1 in 2000
births
Most frequent causes of uterine rupture during:
• Separation of scar of a previous classic cesarean birth
• Uterine trauma (e.g., accidents, surgery)
• Congenital uterine anomaly
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Obstetric Emergencies (Cont.)
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Rupture of the uterus (Cont.)
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During labor and birth
• Intense spontaneous uterine contractions
• Labor stimulation (e.g., oxytocin, prostaglandin)
• Overdistended uterus (e.g., multifetal gestation)
• Malpresentation, external or internal version
• Difficult forceps-assisted birth
• Occurs more in multigravidas than primigravidas
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Obstetric Emergencies (Cont.)
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Amniotic fluid embolus (AFE), also called
anaphylactoid syndrome of pregnancy (ASP)
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Amniotic fluid containing particles of debris (e.g.,
vernix, hair, skin cells, or meconium) enters the
maternal circulation and obstructs pulmonary
vessels, causing respiratory distress and
circulatory collapse
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Key Points
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Preterm birth is any birth that occurs between 20 0/7
and 36 6/7 weeks of gestation.
Preterm labor is generally diagnosed clinically as
regular contractions along with a change in cervical
effacement or dilation or both or presentation with
regular uterine contractions and cervical dilation of at
least 2 cm. The incidence of preterm birth varies
considerably by race. In the United States, nonHispanic black women have the highest rate of
preterm birth.
The cause of preterm labor is unknown and is
assumed to be multifactorial; therefore, it is not
possible to predict with certainty which women will
experience preterm labor and birth.
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Key Points (Cont.)
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Because the onset of preterm labor is often insidious
and can be mistaken for normal discomforts of
pregnancy, nurses should teach all pregnant women
how to detect the early symptoms of preterm labor
and to call their primary health care provider when
symptoms occur.
The best reason to use tocolytic therapy is to achieve
sufficient time to administer glucocorticoids in an
effort to accelerate fetal lung maturity. Additionally,
time is allowed for transport of the woman prior to
birth to a center equipped to care for preterm infants.
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Key Points (Cont.)
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If fetal or early neonatal death is expected, the
parents and members of the health care team need
to discuss the situation before the birth and decide on
a management plan that is acceptable to everyone.
Vigilance for signs of infection is an essential
component of the care management for women with
preterm PROM.
Dysfunctional labor results from differences in the
normal relationships among any of the five factors
affecting labor and is characterized by differences in
the pattern of progress in labor.
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Key Points (Cont.)
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Obese women are at risk for several pregnancy
complications, including cesarean birth. Even routine
procedures require more time and effort to
accomplish when the client is obese.
Uterine contractility is increased by the effects of
oxytocin and prostaglandin and is decreased by
tocolytic agents.
Labor should not be induced electively until the
woman has reached at least 39 weeks of gestation.
Cervical ripening using chemical or mechanical
measures can increase the success of labor
induction.
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53
Key Points (Cont.)
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Expectant parents benefit from learning about
operative obstetrics (e.g., forceps-assisted, vacuumassisted, or cesarean birth) during the prenatal period.
The basic purpose of cesarean birth is to preserve
the well-being of the mother and her fetus.
Unless contraindicated, vaginal birth is possible after
a previous cesarean birth.
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Key Points (Cont.)
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Labor management that emphasizes one-to-one
support of the laboring woman by another woman
(e.g., doula, nurse, nurse-midwife) can reduce the
rate of cesarean birth and increase the VBAC rate.
Obstetric emergencies (e.g., meconium-stained
amniotic fluid, shoulder dystocia, prolapsed cord,
rupture of the uterus, and amniotic fluid embolism)
occur rarely but require immediate intervention to
preserve the health or life of the mother and fetus or
newborn.
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Question
A pregnant woman arrives on the labor and delivery unit
and informs the nurse that her infant is in a breech
presentation. This presentation is associated with an
increased risk for childhood handicap; therefore this
baby will likely be delivered by cesarean birth. The
client may wish to undergo an external cephalic version
(ECV) in an attempt to manually reposition the baby into
a vertex presentation. A number of interventions may be
implemented to support this procedure and increase the
likelihood of success. Studies have shown which
intervention to be the most successful?
a.
b.
c.
d.
Tocolysis
Nitrous oxide
Spinal or epidural analgesia
Amnioinfusion
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