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

Dystocia and Dysfunctional Labor Causes Power Hypotonic Hypertonic Passenger Passage

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.