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Complications of Labor and
Delivery
by: Ann Hearn RNC, MSN
Spring 2009
Copyright © 2005 by Elsevier, Inc. All rights reserved.
The Powers
Complications
• Uterine Dystocia -defined as difficult labor.
– Hypertonic contractions – more frequent
but decreased intensity
– Hypotonic contractions – decrease in
frequency (2-3 UC in 10 min period)
• Also termed uterine inertia
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Interventions for Uterine
Dystocia
Hypertonic Uterus: Contractions are painful but
ineffective resulting in prolonged latent
phase.
• Nursing Interventions:
– Bed rest
– Sedation or pain relief
– Support/educate
– Position changes
– Comfort measures: calm environment, music,
therapeutic touch, back rub, warm shower,
imagery
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Interventions for Uterine
Dystocia
Hypotonic Uterus: results from overstretched
uterine muscle leading to a prolonged active
phase.
• Nursing Interventions:
– Amniotomy
– Pitocin administration
– Emptying bladder
– Hydration
– Teaching/Support
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Amniotomy/Artificial Rupture of
Membranes (AROM)
• Advantages:
– Increases frequency and intensity of uterine
contractions
– Release of prostaglandins
– Facilitates decent of presenting part
– Allows for internal monitoring
– Ability to assess amniotic fluid
• Disadvantages:
– Increased risk for infection
– Possibility of prolapsed umbilical cord
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Artificial Rupture of Membranes
Fig. 20-1d
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Amniotomy/Artificial Rupture
of Membranes (AROM)
• Nursing care
– Place disposable pads and towel underbuttock and change frequently
– Assess FHR before and after amniotomy
• Contraindication:
**Procedure should not be performed if
head is not engaged**
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Bishop Score
• Pre-labor status evaluation scoring system
– A predictor for the potential success of
induction of labor
– A high score indicates the cervix is
favorable and vaginal delivery will likely
occur
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Induction of Labor
Bishop Score
Score
0
1
2
3
Dilation
<1cm
1-2cm
2-4cm
>4cm
Effacement 0-30%
40-50%
60-70%
80%
Fetal
Station
Cervical
-3
-2
-1, 0
+1, +2
Firm
Intermediate Soft
Cervical
Position
Posterior
Intermediate Anterior
Consistency
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Pitocin (Oxytocin)
Administration
Uses of Pitocin:
• Induction – initiates uterine contractions
• Augmentation – enhances ineffective
contraction pattern
Goal:
A labor pattern with uterine contractions
occurring every 2-3 minutes, lasting 40-60
seconds and a return to baseline between
contractions
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Indications for Induction
(ACOG, 1999)
–
–
–
–
Diabetes mellitus
Renal disease
Preeclampsia
Premature rupture
of membranes
– History of rapid
labor
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– Chorioamnionitis
– Postterm gestation
– Mild abruptio
placenta
– IUFD
– IUGR
Pitocin (Oxytocin)
Administration
• Nursing interventions when titrating Pitocin:
– maternal V/S
– FHR pattern
• Baseline
• Variability
• Periodic changes
– Uterine contraction pattern
• Frequency
• Duration
• Interval
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Failure to Progress
Prolonged Labor
• Causes:
–
–
–
–
Labor dystocia
Malposition
Malpresentation
Macrosomia
• Interventions:
– R/O CPD
– Uterine rest
– Pitocin augmentation
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Precipitous Labor
Labor < 3 hours
• Complications:
– Woman
• loss of coping ability
• Lacerations of cervix, vagina, perineum
– Fetus
• Hypoxia
• Cerebral trauma
• Pnemothorax
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Precipitous Labor
Monica, a G1, P0 @ 39.4wks is admitted to
L&D with occasional uterine contractions
that started soon after her BOW broke an
hour ago. She pauses during conversation
to breath during contractions and gives a
pain rating of 5. Monica states she will
probably want an epidural.
While performing the admission
history/assessment you notice that Monica’s
contractions are occurring every 2 minutes
and palpate strong. Monica is beginning to
demonstrate difficulty with coping during
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The Passenger
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Malposition of the Fetus
• Medical Treatments:
– Rotation and delivery by:
• forceps
• vacuum assisted devise
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Internal & External Rotation
(version)
A procedure performed to change the fetal
presentation
• Internal
– Podalic- changing the position of the 2nd
twin after delivery of the 1st via vaginal
manipulation
• External
– Manual rotation of the fetus from breech
to cephalic presentation via external
manipulation of the maternal abdomen
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External Version
Fig. 20-3
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Three Malpresentations
1. Brow: forehead
– C/S delivery
2. Face
– Vaginal delivery
3. Breech
• Frank – buttocks
• Footling – foot/feet
– C/S delivery
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Obstetric Forceps
Fig. 20-4 Middle row
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Obstetric Forceps (cont’d)
Fig. 20-4 Last row
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Birth Assisted with a Vacuum Extractor
Fig. 20-5
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Cephalo-pelvic Disproportion
CPD
Fetus is larger than the pelvic diameter
• Hallmark symptom is failure of the fetus to
descend
Causes:
– diseases affecting bones (rickets), injury
– congenital anomolies, pelvic shape & size
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Cephalo-pelvic Disproportion
CPD
• Diagnosis
– CT scan
– Estimated fetal weight per US
• Trial of labor
– Borderline pelvic diameter
• Support patient
– Keep the patient informed of progress
– Position changes: sitting squatting, hands &
knees may help with descent
– Prepare for possible C/S
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Skin Incisions for Cesarean Birth
Fig. 20-8
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Uterine Incisions for Cesarean Birth
Fig. 20-9
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Vaginal Delivery After
Cesarean Section - VBAC
Increased risk for uterine rupture
• Obtain informed consent
• Nursing Implications
– Large bore IV access
– Continuous EFM
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Premature Rupture of
Membranes - PROM
Spontaneous rupture of membranes prior to
the onset of labor
• Associated conditions:
– Infection
– Previous history of PROM
– Hydramnios
– Multiple pregnancy
– UTI
– Trauma
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Premature Rupture of
Membranes - PROM
• Determine time of PROM
• Verification of PROM:
– Visualization
– Sterile speculum exam
– pH
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Premature Rupture of
Membranes - PROM
• Nursing Assessment
– Vital signs (temp q 2hr)
– Fetal monitoring
– Nature of fluid
– WBC count
• Administration of Celestone - betamethasone
– PPROM: preterm
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Preterm Labor
Defined as: labor that occurs between 20 and
37 weeks gestation.
• Associated conditions
–
–
–
–
–
–
–
Multiple gestation
Hydraminos
UTI
Abdominal trauma
Infection
No prenatal care
Low socio-economic status
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Preterm Labor
• Fetal Fibronectin test
– 99% accurate predictor of NO preterm
birth within 7 days
• Nursing Implications
– Promote rest, hydration, circulation
– Monitor FHR and uterine activity
– Administer tocolytics as ordered
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Preterm Labor
Tocolytics
• Medications prescribed to stop preterm labor
– Terbutaline – B adrenergic receptor
antagonist
– Magnesium sulfate – CNS depressant
– Ritodrine - not FDA approved for PTL
rarely used.
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Tocolytic Drugs
Smooth muscle relaxants
Terbutaline Contraindications: hold and notify HCP if
maternal HR > 140bpm
• Side effects: increase heart rate, feeling of anxiety,
headache, increased blood glucose
Magnesium Sulfate
• Contraindications: discontinue for resp. depression,
magnesium level >8, administer ca+ gluconate
• Side Effects: flushing, headache, nausea, lethargy,
dizziness, decreased DTR, decreased resp. rate,
pulmonary edema
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Ruptured Uterus
• Causes:
– Long difficult labor
– Injudicious use of Pitocin
– Previous C/S
• Assessment Findings
– Fetal bradycardia
– Maternal abdominal pain
• Obstetrical Treatment
– Emergency Cesarean Section delivery
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Uterine Rupture
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Prolapsed Umbilical Cord
Occurs when the umbilical cord precedes the
presenting part.
• Primary Risk Factor
– Fetal head is not engaged or at a high station
Vessels carrying blood to & from the fetus are
compressed, usually results in fetal distress
or possible demise
• Nursing Interventions
– Knee chest position
– Administer O2
– Manual lift of fetal head off the cord
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Variations of Prolapsed
Umbilical Cord
Fig. 27-6a
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Variations of Prolapsed Umbilical Cord
(cont’d)
Fig. 27-6c
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Amniotic Fluid Embolism
In the presence of a small tear in the amnion
and chorion, a small amount of amniotic
fluid may leak into the chorionic plate and
enter the maternal blood system.
Can also occurs at areas of placental
separation, cervical tears or during
trumultuous labor
The more debris (meconium, vernix, lanugo) in
the amnionic fluid, the greater the maternal
problems caused by possible anaphylactic
reaction to fetal antigens
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Amniotic Fluid Embolism
Assessment Findings: Sudden onset
• Respiratory distress (dyspnia)
• Circulatory collapse (cyanosis)
• Tachycardia
• Hypotension
• Acute hemorrhage
• Cor Pulmonale
• Frothy sputum
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Amniotic Fluid Embolism
Obstetrical Emergency
• Interventions:
–
–
–
–
–
Large bore IV line
Positive pressure oxygen
CPR
Blood transfusion - DIC
Emergency C/S if pregnant
Prognosis – 50% of women die with the first hour of
symptoms
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