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Complications of Labor and Delivery

Dystocia - An abnormal, long, or difficult labor or delivery


COMPLICATIONS OF THE PSYCHE

Etiology and Pathophysiology:


Hormones released in response to anxiety can cause DYSTOCIA

Intense anxiety stimulates Sympathetic nervous system which releases catecholamines


that lead to myometrial dysfunction.

Norepinephrine and epinephrine lead to uncoordinated or increased uterine activity

Nursing Care

Assess support available and be there for the patient


Patient Teaching- breathing/relaxation
Provide with non-pharmacological measures
Keep informed
Provide quiet calm environment
HYPERTONIC UTERINE CONTRACTIONS

Most often occur in first-time mothers, Primigravidas

Provide with COMFORT MEASURES


Warm shower; Mouth Care; Imagery; Music; Back rub

Mild sedation

Contractions are ineffectual, erratic, uncoordinated, and involve only a portion of the uterus

Increase in frequency of contractions, but intensity is decreased, do not bring about dilation
and effacement of the cervix.
Signs and Symptoms:
1. PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain
2. Dilation and effacement of the cervix does not occur.
3. Prolonged latent phase. Stay at 2 - 3 cm. dont dilate as should
4. Fetal distress occurs early uterine resting tone is high, decreasing placental perfusion.
5. Anxious and discouraged
Treatment of Hypertonic Uterine Contractions

Bedrest
Hydration
Tocolytics to reduce high uterine tone

HYPOTONIC UTERINE CONTRACTIONS


UTERINE INERTIA

Etiology and Pathophysiology:

Overstretching of the uterus --large baby, multiple babies, polyhydramnios, multiple parity
Bowel or bladder distention preventing descent
Excessive use of analgesia
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Signs and Symptoms of HYPOTONIC UTERINE INERTIA:

Weak contractions become mild


Infrequent (every 10 15 minutes +) and brief,
Can be easily indented with fingertip pressure at peak of contraction.
Prolonged ACTIVE Phase
Exhaustion of the mother
Psychological trauma - frustrated
Therapeutic Interventions:
1. Ambulation getting up and walking will increase contractions
2. Nipple Stimulation causes release of endogenous Pitocin which can stimulate
contractions
3. Enema--warmth of enema may stimulate contractions
4. AMNIOTOMY artificial rupture of the membranes
Advantages of doing this before Pitocin
Contractions are more similar to those of spontaneous labor
Usually no risk of rupture of the uterus
Does not require as close surveillance
Disadvantages of an Amniotomy
Delivery must occur
Increase danger of prolapse of umbilical cord
Compression and molding of the fetal head (caput)
Nursing Care:
# 1-Check the fetal heart tones
Assess color, odor, amount
Provide with perineal care
Monitor contractions
Check temperature every 2 hours

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Pitocin for augmentation of labor

Use only if CPD is not present


Give 20 units / 1000 cc. fluid and hang as a secondary infusion, never as primary
GOAL:
Achieve contractions every 2 - 3 minutes of good intensity with relaxation between
Nursing Care:
Assess contractions--are they increasing but not tetanic
Assess dilation and effacement
Monitor vital signs and FHTs
Prolonged Labor
Definition: A labor lasting more than 18-24 hours
Normally:
Cervical dilation -- Primigravida 1.2 cm / hr. Multigravida 1.5 cm / hr
Descent 1 cm. / hr in primigravida and 2 cm./ hr. in multigravida
PRECIPITIOUS LABOR OR DELIVERY
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Labor that last less than 3 hours


Unexpected fast delivery
Etiology
Lack of resistance of maternal tissue to passage of fetus
Intense uterine contractions
Small baby in a favorable position
Complication:
If the baby delivers too fast, does not allow the cervix to dilate and efface which leads to
cervical lacerations
Uterine rupture
Fetal hypoxia and fetal intracranial hemorrhage
Rapid Delivery
Delivery Outside Normal Setting
Everything is OUT OF CONTROL!
mom is frightened, angry, feels cheated
Nursing Care:
Do NOT leave the mother alone
Try to make the place clean, (dont break down table)
Try to get the mother in control -- Have mom pant to decrease the urge to push
Apply gentle pressure to the fetal head as it crowns to prevent rapid change in pressure in
the fetal head which can cause subdural hemorrhage or dural tears.
Deliver the baby BETWEEN contractions to control delivery
Suction or hold babys head low and place on mom/s abdomen, tie off cord
Allow to breast feed, Document!
Pelvic Dystocia

Definition:

Etiology

Pelvic Inlet or Outlet is not of sufficient size or proper shape to allow the baby to get
through
Congenital defect
Malnutrition -- Rickets
Neoplasms
Fracture / Trauma

Signs and Symptoms:

Labor is arrested.

Station does not decrease. Baby does not move down in the birth
canal after long time in labor or with prolonged pushing.

Therapeutic Interventions:

cesarean delivery
Complications of the Passenger

Malpositions:

Posterior position--usually mom complains of back pain

Treatment:

Forceps -- low

forceps or outlet forceps usually applied after crowning


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Vacuum extraction -- disk shaped cup placed over vertex of head and vacuum applied.
Episiotomy - surgical incision to allow more room

Malpresentation -- brow, face, transverse, breech


may allow to deliver vaginally with caution or Cesarean birth

Treatment:

May allow to deliver with caution or C-birth

Version -- alteration of fetal position by abdominal or intrauterine manipulation

Cephalopelvic Disproportion
Large baby or small pelvis
Usually diagnosed when there is an arrest in descent
Station remains the same
Treatment:
Cesarean Delivery
Multiple Fetus
may be delivered by cesarean birth

CESAREAN DELIVERY
OPERATIVE PROCEDURE IN WHICH THE FETUS IS DELIVERED THROUGH AN INCISION IN
THE ABDOMEN
REMEMBER -- IT IS A BIRTH !
Mom may feel less than normal, so may need support
May have option of a VBAC the next time
Premature Rupture of the Membranes / PROM

Definition:

Spontaneous rupture of the membranes

Etiology

Infections
Fetal abnormalities

- Incompetent cervix
- Sexual Intercourse

Major risk - ascending intrauterine infection

Treatment and Nursing Care:

Other risk -- Precipitation of labor

Wait and watch, bedrest, no intercourse


Betamethasone / Celestone -- provides stressor to the lungs of the fetus to stimulate
production of surfactant

Assess time membranes ruptures and if labor started


Check temperature frequently
Describe character of amniotic fluid
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Check WBC
Provide psychological support
Preterm Labor
Definition:
Labor that occurs after 20 weeks but before 37 weeks
Etiology:
urinary tract infections
Premature rupture of membranes
Goal -- STOP THE LABOR ! suppress uterine activity
Therapeutic Interventions:

Drug Therapy / Tocolytics


Uses: Stop or arrest labor
Criteria for use, dont give if:
Patient is in Active labor, cervix has dilated to 4 cm. or more
Presence of Severe Pre-eclampsia
Fetal complications / Fetal demise
Hemorrhage is present
Ruptured membranes
Examples:
Yutopar (ritodrine) or Brethine (terbutaline sulfate)
SIDE EFFECTS or WARNING SIGNS:
Palpitations
Tachycardia - pulse ~120
Tremors, nervousness, restlessness
Headache, severe dizziness
Hyperglycemia

TOXIC EFFECTS - PULMONARY EDEMA


- rales, crackles, dyspnea
- Must perform chest assessment with nursing assessment every shift
and chart lung sounds.
Nursing Care:

Stop the medication


Start oxygen
Give ANTIDOTE: INDERAL
Patient Teaching:
Teach how to take medication -- on time
Teach patient to check pulse, call Dr. if > 120 140 (dehydration increases
contractions)
Teach to assess fetal movement daily, kick counts
Drink 8-10 glasses of water per day
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Monitor uterine activity -- Home monitoring -- call dr. if has contractions


Decrease activity
Lie on side
Keep bladder empty

Ruptured Uterus
Spontaneous or traumatic rupture of the uterus
Etiology:
Rupture of a previous C-birth scar
Prolonged labor
Injudicious use of Pitocin -- overstimulation
Excessive manual pressure applied to the fundus during delivery
Signs and Symptoms:
Sudden sharp abdominal pain, abdominal tenderness
Cessation of contractions
Absence of fetal heart tones
Shock
Therapeutic Interventions:
Deliver the baby ! / Cesarean Delivery

Prolapse of the Umbilical Cord


Definition:
Prolapse of the umbilical cord thorough the cervical canal along side of the presenting part
Etiology:
Occurs anytime the inlet is not occluded. Fetus is not well engaged
GOAL:
RELIEVE THE PRESSURE ON THE CORD
SUPPORT MOTHER AND THE FAMILY
NURSING CARE / Therapeutic Interventions:
**Get the pressure off the Cord --place in trendelenberg or knee-chest position OR elevate
part with sterile gloved hand
Palpate FHTs, NEVER ATTEMPT TO REPLACE CORD!
Give O2 per mask at 10 Liters
Cover exposed cord with sterile wet gauze
Stay with the patient and offer support
Amniotic Fluid Embolism

dyspnea
chest pain
cyanosis
shock

Escape of amniotic fluid into the maternal


circulation

usually enters maternal circulation


through open sinus at placental site

Usually fatal to the Mother

amniotic fluid contains debris, lanugo,

Therapeutic Interventions:

Deliver the baby

vernix, meconium, etc.

Signs and Symptoms:


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Provide cardiovascular and respiratory


support to Mom