Complications of Labor and Delivery

2. Dystocia An abnormal, long, or difficult labor or delivery 1. Describe uterine dystocia. 1. Describe uterine dystocia.

3. Successful completion of a pregnancy requires the harmonious functioning of the critical factors in labor. When this does not occur, it is noted as a dysfunctional labor. Successful completion of a pregnancy requires the harmonious functioning of the critical factors in labor. When this does not occur, it is noted as a dysfunctional labor.

5. HYPOTONIC UTERINE CONTRACTIONSUTERINE 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

6. ASSESSMENT 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 c. What are the signs and symptoms of hypotonic uterine contractions?c. What are the signs and symptoms of hypotonic uterine contractions?

7. Friedman�s GraphHypotonic Uterine Contractions

8. Therapeutic Interventions Ambulation Nipple Stimulation --release of endogenous Pitocin Enema--warmth of enema may stimulate contractions Amniotomy--artificial rupture of the membranes Augmentation of labor with Pitocin d. What interventions might the nurse implement?d. What interventions might the nurse implement?

9. Amniotomy Amniotomy is the artificial rupture of the amniotic sac with a tool called the amniohook (a long crochet type hook, with a pricked end) or an amnicot (a glove with a small pricked end on one finger). One of these will be placed inside the vagina, where the caregiver will rupture the amniotic sac or membrane. Birth Related Procedures � to assist with hypo and hypertonic uterine contractions: 2. Define the term amniotomy and related nursing care. P. 435 Birth Related Procedures � to assist with hypo and hypertonic uterine contractions: 2. Define the term amniotomy and related nursing care. P. 435

11. AMNIOTOMY 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) What are advantages to performing an amniotomy? What are disadvantages to performing an amniotomy? What nursing care is required for this procedure? When is this procedure contraindicated?What are advantages to performing an amniotomy? What are disadvantages to performing an amniotomy? What nursing care is required for this procedure? When is this procedure contraindicated?

12. Amniotomy Nursing Care: # 1-Check the fetal heart tones Assess color, odor, amount Provide with perineal care Monitor contractions Check temperature every 2 hours

14. Answer

15. Cervical Ripening

16. Cervical Ripening prostaglandin E2 Medications Prepidil gel Cervodil Prostaglandin E1 Medication Cytotec Nursing Care Monitor maternal vital signs, cervical dilatation and effacement Monitor fetal status for presence of reassuring fetal heart rate Remove medication if hyperstimulation occurs 3. What is cervical ripening? What medications are used and related nursing care?3. What is cervical ripening? What medications are used and related nursing care?

17. Hyperstimulation Remove the medication Turn patient to side-lying position Provide oxygen via face mask Give Terbutaline

18. PITOCINAugmentation of Labor Assess first to make sure CPD is not present, then start procedure: Give 10 units / 1000 cc. fluid and hang as a secondary infusion, never as primary Nursing Care: Assess contractions--are they increasing but not tetanic Assess dilation and effacement Monitor vital signs and FHT�s Make sure no signs of hyperstimulation before increasing dose

19. HYPERTONIC UTERINE CONTRACTIONS Most often occur in first-time mothers, Primigravidas Contractions are ineffectual, erratic, uncoordinated, and of poor quality that 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. a. What are hypertonic uterine contractions?a. What are hypertonic uterine contractions?

20. Signs and Symptoms PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain Dilation and effacement of the cervix does not occur. Prolonged latent phase. Stay at 2 - 3 cm. don�t dilate as should Fetal distress occurs early� uterine resting tone is high, decreasing placental perfusion. Anxious and discouraged 2. What are the signs and symptoms of hypertonic uterine contractions?2. What are the signs and symptoms of hypertonic uterine contractions?

21. Friedman�s GraphHypertonic Uterine Contractions

22. Relieve pain and promote normal labor pattern

23. Treatment of Hypertonic Uterine Contractions Provide with COMFORT MEASURES Warm shower Mouth Care Imagery Music Back rub, therapeutic touch Mild sedation Bedrest or position changes Hydration Tocolytics to reduce high uterine tone b. What interventions would the nurse implement when caring for a woman experiencing hypertonic uterine contractions? b. What interventions would the nurse implement when caring for a woman experiencing hypertonic uterine contractions?

24. Ineffective Maternal Pushing Results from: Incorrect pushing techniques Fear of injury Decreased urge to push Maternal exhaustion Treatment Teaching

26. Fetal Size Macrosomia Infant weighs more than 8 lb. 13 oz. Shoulder dystocia McRoberts maneuver Suprapubic pressure

27. Abnormal Presentation and Positions Malpositions: Posterior position--usually mom complains of back pain Malpresentation Brow - Face - Breech - Transverse -

28. Problems of Passenger Cephalopelvic Disproportion (CPD) Large baby or small pelvis Usually diagnosed when there is an arrest in descent Station remains the same Multiple Fetus Twins, triplets, etc.

29. Treatments for Complications of the Passenger Positioning � hands and knees, lunge to side Version -- alteration of fetal position by abdominal or intrauterine manipulation Amnioinfusion - infusion into the uterine cavity Forceps -- low forceps or outlet forceps usually applied after crowning Vacuum extraction -- disk shaped cup placed over vertex of head and vacuum applied. Episiotomy - surgical incision to allow more room Cesarean Delivery

30. External Version Procedure External (or cephalic) version of the fetus. A new technique involves pressure on the fetal head and buttocks so that the fetus completes a �backward flip� or �forward roll.� External (or cephalic) version of the fetus. A new technique involves pressure on the fetal head and buttocks so that the fetus completes a �backward flip� or �forward roll.�

31. External Version Procedure Criteria Fetus is not engaged A reactive NST 36+ weeks gestation Contraindications A complicated pregnancy Multiple pregnancy Non-reassuring FHR Nursing Care Administer terbutaline prior to start Monitor maternal and fetal vital sign Post � assess for contractions and kick-counts 8. What is a version procedure? a. criteria b. contraindications c. nursing care8. What is a version procedure? a. criteria b. contraindications c. nursing care

32. Episiotomy The two most common types of episiotomy are midline and mediolateral. A, Right mediolateral. B, Midline. 10. What is an episiotomy? The two most common types of episiotomy are midline and mediolateral. A, Right mediolateral. B, Midline. 10. What is an episiotomy?

33. Episiotomy Factors that predispose: Primigravida Large baby, macrosomia Posterior position of baby Use of forceps or vacuum extractor Preventive Measures Perineal massage Side-lying for expulsion Gradual expulsion Nursing Care Provide comfort and patient teaching After delivery- apply ice and assess site 10. a. What factors predispose a woman to an episiotomy? b. What are preventive measures? c. What is the nursing care for a woman with an episiotomy? 10. a. What factors predispose a woman to an episiotomy? b. What are preventive measures? c. What is the nursing care for a woman with an episiotomy?

34. Forceps-assisted Delivery During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal. 11. What are the indications for a forceps-assisted delivery? During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal. 11. What are the indications for a forceps-assisted delivery?

35. Forceps-Assisted Delivery Risks Fetus Facial edema or lacerations Caput succedaneum or cephalohematoma Maternal Lacerations of birth canal Perineal bleeding, bruising, edema Nursing Care Preventive measures to decrease need for forceps Patient teaching After � assessment of newborn and assessment of woman�s perineum. 11. What are the risks of using forceps? What is the related nursing care? 11. What are the risks of using forceps? What is the related nursing care?

36. Vacuum Extraction Vacuum extractor traction. A, The cup is placed on the fetal occiput and suction is created. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, traction is maintained to lift the fetal head out of the vagina. Vacuum extractor traction. A, The cup is placed on the fetal occiput and suction is created. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, traction is maintained to lift the fetal head out of the vagina.

37. Vacuum Extraction Used to shortening the second stage of labor and delivery of the fetus Risk Cephalohematoma or caput succedaneum Nursing Care Keep woman and partner informed during the procedure After � assess newborn 12. What is the purpose of performing a vacuum-assisted birth? What are the major complications? 12. What is the purpose of performing a vacuum-assisted birth? What are the major complications?

38. 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 13. Discuss the nursing care related to the woman having a cesarean birth. 13. Discuss the nursing care related to the woman having a cesarean birth.

39. VBACVaginal Birth After Cesarean A woman may be considered a candidate for a VBAC if the following guidelines are met: With previous C-section, had low transverse incision Has an adequate pelvis (absence of pelvic dystocia) A woman who had a previous VBAC Hospital must be set up to perform an emergency cesarean within 30 minutes. 14. What are the guidelines considered prior to a VBAC? What are the complications? 14. What are the guidelines considered prior to a VBAC? What are the complications?

40. Cesarean Birth Nursing Care Frequent monitoring of woman and fetus Complication Uterine rupture

42. Cephalopelvic Disportion (CPD) Causes Large baby or small pelvis Usually diagnosed when there is an arrest in descent Symptoms Station remains the same does not descend Treatment and Nursing Care Usually do a cesarean delivery if cause is pelvis Utilize other measures such as forceps, vacuum extraction, episiotomy. Define the term cephalopelvic disproportion (CPD): a. What are the causes of CPD? b. What are the symptoms for CPD in the laboring woman? c. What is the medical treatment for CPD? Define the term cephalopelvic disproportion (CPD): a. What are the causes of CPD? b. What are the symptoms for CPD in the laboring woman? c. What is the medical treatment for CPD?

46.  Prolonged Labor Failure to ProgressDefinition: A labor lasting more than 18 - 24 hours or fails to make changes in dilation or effacement Cervical dilation -- Primigravida 1.2 cm / hr. Multigravida 1.5 cm / hr Descent � 1 cm. / hr in primigravida and 2 cm./ hr. in multigravida Discuss the term failure to progress in labor: What factors may cause a prolonged labor? What interventions are appropriate for a woman experiencing failure to progress? Discuss the term failure to progress in labor: What factors may cause a prolonged labor? What interventions are appropriate for a woman experiencing failure to progress?

47. Etiology CPD - Cephalo Pevlic Disportion Malpresentation, malposition Labor dysfunction Therapeutic Interventions depends on the cause Provide comfort measures Conservation of energy Psychological support Position changes What factors may cause a prolonged labor? What interventions are appropriate for a woman experiencing failure to progress? What factors may cause a prolonged labor? What interventions are appropriate for a woman experiencing failure to progress?

48. PRECIPITIOUS LABOR OR DELIVERY 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 Complications/ Risks: 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 6. What is precipitous labor? What are the risks associated with a precipitous labor? For the woman- For the fetus- 6. What is precipitous labor? What are the risks associated with a precipitous labor? For the woman- For the fetus-

49. Rapid DeliveryDelivery 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, (don�t 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 baby�s head low and place on mom/s abdomen, tie off cord Allow to breast feed, Document! What is the nursing care for a precipitous labor? (p. 502) What is the nursing care for a precipitous delivery and potential complications? (p. 475-477) What is the nursing care for a precipitous labor? (p. 502) What is the nursing care for a precipitous delivery and potential complications? (p. 475-477)

51. Premature Rupture of the Membranes Definition: Spontaneous rupture of the membranes Etiology Infections - Incompetent cervix Fetal abnormalities - Sexual Intercourse Major risk - ascending intrauterine infection Other risk -- Precipitation of labor 19. Define premature rupture of membranes (PROM): What conditions are associated with PROM? What assessments should the nurse make in the case of PROM? 19. Define premature rupture of membranes (PROM): What conditions are associated with PROM? What assessments should the nurse make in the case of PROM?

52. Treatment and Nursing Care: Wait and watch, bedrest, no intercourse Assess time membranes ruptures and if labor started Check temperature frequently Describe character of amniotic fluid Check WBC Provide psychological support 19. c. Why is the mediation Celestone administered after PROM? �19. c. Why is the mediation Celestone administered after PROM? �

53. Accelerating Fetal Lung Maturity Betamethasone (Celestone) or dexamethasone(Decadron are given to stimulate the lungs and accelerate fetal lung maturity thereby decreasing chance of respiratory distress syndrome. Lasts for about 7 days and need to repeat/

55. 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 20. Define Preterm labor: What conditions are associated with preterm labor?20. Define Preterm labor: What conditions are associated with preterm labor?

56. Therapeutic InterventionsDrug TherapyTocolytics Uses: Stop or arrest labor Criteria for use, don�t 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

57. TOCOLYTIC MEDICATIONS�-adrenergic agonist 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 noted on routine nursing chest assessment every shift

58. Tocolytic Drugs Nursing Care: Stop the medication Start oxygen Give ANTIDOTE: INDERAL

59. Tocolytic MedicationsMagnesium Sulfate Decreases frequency and intensity of uterine contractions Given via IV infusion pump Loading dose 4-6 g in 100 ml given over ~20 minutes Maintenance dose � 1-4 g per hour. Side effects Lethargy and weakness Sweating, flushing, N/V, headache, slurred speech Toxic effects Absences of reflexes Respiratory depression

60. Tocolytic MedicationsCalcium Channel Blockernifedipine Decreases smooth muscle contraction by blocking the slow calcium channels at cell surface. Administration Orally or sublingually Side Effects Hypotension, tachycardia Facial flushing Headache

61. Tocolytic Medicationsprostaglandin synthesis inhibitorindomethacin (Indocin) Action Inhibits prostaglandin synthesis thus reducing uterine contractions. (Prostaglandins stimulate uterine contractions) Used for pregnancies <32 weeks gestation and not given for more than 72 hours. Not a widely used medication to treat preterm labor.

62. Self Care Measures Rest Drink plenty of fluids � 2-3 quarts /day Empty bladder every 2-3 hours when awake Avoid lifting heavy objects Avoid overexertion Modify sexual activity d. What are self-care measures to prevent preterm labor? d. What are self-care measures to prevent preterm labor?

63. Preterm labor NURSING CARE: 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 Monitor uterine activity -- Home monitoring -- call dr. if has contractions Decrease activity Lie on side Keep bladder empty

64. Accelerating Fetal Lung Maturity Betamethasone / Celestone -- provides stressor to the lungs of the fetus to stimulate production of surfactant Effective if have 24 hours prior to delivery

68. Prolapse of Cord

69. Prolapse of the Umbilical Cord Definition: Prolapse of the umbilical cord thorough the cervical canal along side of the presenting part Etiology/ Risk Factor: Occurs anytime the inlet is not occluded. Fetus is not well engaged GOAL: RELIEVE THE PRESSURE ON THE CORD SUPPORT MOTHER AND THE FAMILY 15. Define prolapse of the umbilical cord. What is the primary risk factor for prolapse of the umbilical cord? � 15. Define prolapse of the umbilical cord. What is the primary risk factor for prolapse of the umbilical cord? �

70. Prolapse of the Cord NURSING CARE / Therapeutic Interventions: #1 � Get the Pressure off the Cord place in trendelenberg or knee-chest position OR elevate part with sterile gloved hand 15. What are specific nursing interventions for a prolapsed cord? 15. What are specific nursing interventions for a prolapsed cord?

71. 9. What is the purpose of performing an amnioinfusion? What is the related nursing care? 9. What is the purpose of performing an amnioinfusion? What is the related nursing care?

72. Amnioinfusion Used to treat: Oligohydramnios Meconium-stained amniotic fluid Cord compression and variable decelerations Nursing Care Assess maternal and fetal vital signs Assess contractions Provide comfort measures Measure intake and output of the fluid 9. What is the purpose of performing an amnioinfusion? What is the related nursing care? 9. What is the purpose of performing an amnioinfusion? What is the related nursing care?

73. Nursing Care for Prolapse of Umbilical Cord Palpate FHT�s, 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

74. Amniotic Fluid Embolism 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, vernix, meconium, etc. 16. What is the cause of an amniotic-fluid embolism: 16. What is the cause of an amniotic-fluid embolism:

75. Amniotic Fluid Embolism Signs and Symptoms: dyspnea chest pain cyanosis shock Therapeutic Interventions: Deliver the baby Provide cardiovascular and respiratory support to Mom 16. a. What assessment findings lead to a diagnosis of amniotic embolism? b. What are the interventions for an amniotic embolism? 16. a. What assessment findings lead to a diagnosis of amniotic embolism? b. What are the interventions for an amniotic embolism?

76. 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 What is a complication of a VBAC?What is a complication of a VBAC?

79. The stimulation of uterine contractions before the spontaneous onset of labor, for the purpose of accomplishing birth

80. Labor Readiness Fetal Maturity Cervical Readiness with utilization of the PreLabor Status Evaluation Scoring System/ Bishop�s score Assesses cervical dilatation, effacement, consistency, position, and fetal station. A score of 8-9 is favorable for induction Discuss the purpose of assigning a Bishop�s score. See Table 22-1 on page 544Discuss the purpose of assigning a Bishop�s score. See Table 22-1 on page 544

81. Methods of Inducing Labor Stripping the Membranes With a gloved finger, the amniotic membranes lying against the lower uterine segment are separated. This causes release of prostaglandins that stimulate uterine contractions Pitocin Infusion The goal is to have contractions occurring every 2 minutes of good intensity with relaxation between. Used for induction and augmentation. Pitocin augmentation � means to return contractions to where there were as in hypotonic contractions. Induction is to start from beginning with no contractions. GOAL: Pitocin augmentation � means to return contractions to where there were as in hypotonic contractions. Induction is to start from beginning with no contractions. GOAL:

82. Other Methods of Induction Ambulation Nipple Stimulation --release of endogenous Pitocin Enema--warmth of enema may stimulate contractions Herbs Insertion of balloon catheter Other methods � baloon insertion - insert a rubber balloon on the end of a tube (a Foley catheter) through the cervix. The balloon is inflated with water. Apparently, the pressure on the inside of the cervix gives the signal for dilation.Other methods � baloon insertion - insert a rubber balloon on the end of a tube (a Foley catheter) through the cervix. The balloon is inflated with water. Apparently, the pressure on the inside of the cervix gives the signal for dilation.

83. The End

85. Polyhydramnios and oligohydramnios Polyhydramnios � excessive amniotic fluid usually > 2000 ml. Associated with fetal GI anomalies and maternal diabetes Treatment � watch and do nothing unless becomes short of breath and in pain � then do an amniocentesis Oligohydramnios � scanty amniotic fluid usually <500 ml. Etiology unknown Risks � fetal adhesions and fetal malformations Treatment - amnioinfusion 17. Compare polyhydramnios with oligohydramnios.17. Compare polyhydramnios with oligohydramnios.