1. Childbirth at Risk: Labor Complications
Twila Brown, PhD, RN

2. Dystocia and Dysfunctional Labor
Causes
Power
Hypotonic
Hypertonic
Passenger
Passage

3. Dysfunctional Uterine Contractions: Hypertonic Labor Patterns
Latent phase of labor
Contractions
Ineffective in dilating and effacing the cervix
Resting tone of myometrium increases
Occur more frequent
Painful
Maternal risks
Fetal risks

4. Dysfunctional Uterine Contractions: Hypertonic Labor Patterns
Management
Assess for cephalopelvic disproportion (CPD)
Bed rest and sedation
Oxytocin or amniotomy
Decrease pain and anxiety
Monitor fetal heart rate patterns
Provide fluids and glucose

5. Dysfunctional Uterine Contractions: Hypotonic Labor Patterns
Active phase of labor
Etiology
Sedation, over-distension of the uterus, bladder or bowel distention
Advancing maternal age
Contractions
Low amplitude
Fewer than 2-3 contractions in 10 minutes
Irregular pattern
Cervical dilation less than 1 cm per hour

6. Dysfunctional Uterine Contractions: Hypotonic Labor Patterns
Management
Assess for CPD and engagement
Amniotomy
Oxytocin
Provide comfort and decrease anxiety
Monitor mother
Monitor fetus

7. Precipitous Labor and Birth
Labor and birth less than 3 hours
Intense contractions
Little relaxation between contractions
Rapid cervical dilation and fetal descent
Maternal risks
Fetal risks

8. Precipitous Labor and Birth
Management
Tocolytic agent
Immediate delivery
Support for relaxation
Monitor contractions and fetal heart rate
Apply pressure to fetal head

9. Fetal Position Most common at delivery Cephalic – Vertex
Chin flexed to chest
Occiput Anterior

10. Fetal Malposition: Occiput-posterior
Assessment
Intense back pain
Poor dilatation and descent
Depression in lower maternal abdomen
Fetal heart rate heard laterally
Anterior fontanelle in anterior
Perineal laceration or episiotomy extension
Management
Manual rotation
Side-lying or knee-chest
Forceps

11. Fetal Malpresentation: Military, Brow, and Face
Management
Cesarean birth if CPD
Monitor for fetal hypoxia
Episiotomy extension
Forceps or manual conversion contraindicated
Newborn trauma

12. Fetal Malpresentation: Breech
Assessment
Fetal head, feet, bottom, and heart tones
Management
External cephalic version
Cesarean delivery
Small maternal pelvis
Fetal weight <1500gm or >3800gm
Neck hyperextension, arms over head, anomalies
If vaginal delivery
Pain management, prolapsed cord, head trauma

13. Fetal Malpresentation: Shoulder (Transverse lie)
Assessment
Maternal abdomen
Fetal head
Presenting part
Management
External version attempted
Cesarean delivery
Monitor for prolapsed cord

14. Multiple Gestation Risks Management
Hypertension or preeclampsia, anemia, hydramnios
Preterm birth, abnormal fetal presentation
Overstretched uterus, postpartum hemorrhage
Monochorionic placenta or Monoamniotic
Management
Prevent preterm labor
Monitor each fetus
May have Cesarean delivery
Risks:
Problems with pregnancy: hypertension or preeclampsia, anemia, hydramnios
Problems with delivery: preterm birth, abnormal fetal presentation
Delivery and postpartum problems: overstretched uterus (difficult for contractions) and postpartum hemorrhage
Monochorionic placenta: twin to twin transfusion
Monoamniotic: risk of tangled or knotted umbilical cords
Management
Prevent preterm labor
Monitor each fetus during labor and delivery
Cesarean delivery to reduce risk of complications

15. Nonreassuring Fetal Status: Fetal Distress
Etiology
Uteroplacental insufficiency
Fetal hypoxia
Assessment
Late or severe variable decelerations
Decrease in variability
Changes in baseline
Meconium staining of amniotic fluid
Fetal scalp blood pH below 7.20

16. Nonreassuring Fetal Status
Management
Maternal position
Increase intravenous fluid
Oxygen
Discontinue oxytocin
If fetal distress continues, cesarean delivery and resuscitate
If delivery is imminent, deliver and resuscitate

17. Cephalopelvic Disproportion (CPD)
Signs
Slow cervical dilation and effacement
Lack of fetal engagement and descent
Maternal risks
Prolonged labor
Premature rupture of membranes
Uterine rupture
Fetal risks
Prolapsed umbilical cord
Head trauma

18. Cephalopelvic Disproportion
Management
Monitor progression of labor
Monitor for fetal distress
Emotional support
Cesarean delivery
Maternal position
McRoberts maneuver

19. Prolapsed Umbilical Cord
Etiology
Not engaged when membranes rupture
Contributing factors
Assessment
Cord through the cervix
Fetal heart rate is irregular
Cord compressed
Occludes blood flow to fetus
Compression worsens during contractions
Emergency

20. Prolapsed Umbilical Cord
Management
Bed rest until engagement if ruptured membranes
Relieve cord pressure
Push back the presenting part
Fill bladder
Change maternal position
Administer oxygen
Monitor fetal heart tones
Cesarean delivery

21. Abruptio Placentae Etiology Maternal risks Fetal/neonatal risks
Decreased blood flow to the placenta
Maternal hypertension, abdominal trauma, cocaine
Maternal risks
Hypoxic uterus
Uterus difficult to contract after delivery
Maternal hemorrhagic shock
Fetal/neonatal risks
Complications from preterm labor, anemia, and hypoxia

22. Abruptio Placentae Assessment Fundal height increases
May or may not have vaginal bleeding
Painful
Irritable uterus
Rigid, boardlike abdomen
Enlarged uterus
Signs of shock

23. Abruptio Placentae Management
Monitor vital signs and fetal heart tones
Assess vaginal bleeding, pain, and fundal height
Bed rest
Administer oxygen, IV fluids, and blood products
Monitor and treat hypovolemia
Induce vaginal delivery if mild separation:
Cesarean delivery for moderate to severe separation or fetal distress

24. Placenta Previa Etiology Signs Types
Placenta implanted in lower uterine segment
Placental villi are torn from uterus
Signs
Painless, bright red vaginal bleeding
Soft, nontender uterus
High presenting part
Types
Low-lying, Partial, Total

25. Placenta Previa Management
Monitor vital signs, fetal heart rate, fetal activity
Assess amount and quality of bleeding
Vaginal exam is contraindicated
Ultrasound
Administer oxygen as prescribed for fetal distress
Preterm: Bed rest and monitor
Term with low-lying or marginal: Induce for delivery
Cesarean if complete previa or fetal distress

26. Intrauterine Fetal Death
Loss of heart rate on ultrasound and drop in maternal estriol levels
Induce labor or spontaneous labor within 2 weeks
Parental reaction
Supportive care

27. References
Ladewig, P.A., London, M.L., & Davidson, M.R. (2006). Contemorary maternal-Newborn Nursing Care (6th ed.). Upper Saddle River, NJ: Prentice Hall.
Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning.
Olds, S.B., London, M.L., Ladewig, P.W., & Davidson, M.R. ( 2004). Maternal-newborn nursing & women’s health care (7th ed.). Upper Saddle River, NJ: Prentice Hall.
Silvestri, L.A. (2002). Saunders comprehensive review for NCLEX-RN (2nd ed.). Philadelphia: W.B. Sanders.
Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.