3. COMPLICATIONS DURING LABOR AND BIRTH
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What is the main purpose of an episiotomy during childbirth?

  • To speed up the delivery process
  • To reduce the need for anesthesia
  • To increase the risk of tearing
  • To create a controlled enlargement of the vaginal opening (correct)

    • Which condition is considered a contraindication for cesarean birth?

  • Maternal disease
  • Fetal death (correct)
  • Abnormal labor
  • Gestational hypertension

    • What are common maternal risks associated with forceps or vacuum extraction procedures?

  • Lacerations and hematoma of the vagina (correct)
  • Infection and blood clots
  • Respiratory problems
  • Injury to the urinary tract

    • What is a primary indication for considering labor induction?

    <p>Gestational hypertension</p> Signup and view all the answers

    Which nursing intervention is appropriate for managing pain after an episiotomy?

    <p>Cold packs for the first 12 hours</p> Signup and view all the answers

    Which of the following states is NOT considered a contraindication for labor induction?

    <p>Chronic hypertension</p> Signup and view all the answers

    What is a potential infant risk associated with the use of vacuum extraction?

    <p>Facial asymmetry</p> Signup and view all the answers

    What aspect is NOT included in the preoperative nursing considerations for cesarean birth?

    <p>Administering analgesics</p> Signup and view all the answers

    What is a primary reason for inducing labor in a pregnant client?

    <p>Hazardous conditions for mother or fetus</p> Signup and view all the answers

    Which of the following is a contraindication to labor induction?

    <p>Placenta previa</p> Signup and view all the answers

    What complication can arise from an amniotomy?

    <p>Placental abruption</p> Signup and view all the answers

    What condition is NOT an indication for labor induction?

    <p>Maternal obesity</p> Signup and view all the answers

    Following an amniotomy, what nursing implication is essential?

    <p>Observe amniotic fluid's color and odor</p> Signup and view all the answers

    Which method is commonly used to stimulate contractions pharmacologically?

    <p>Misoprostol (Cytotec)</p> Signup and view all the answers

    What is the primary purpose of using oxytocin (Pitocin) during labor?

    <p>Induce or augment contractions</p> Signup and view all the answers

    Which nursing action should be performed when non-reassuring fetal patterns are noted during oxytocin administration?

    <p>Notify the healthcare provider and reposition the patient</p> Signup and view all the answers

    What is a potential complication of using amnioinfusion?

    <p>Variable decelerations in fetal heart rate</p> Signup and view all the answers

    Which nursing action is necessary after administering tocolytic drugs during an external version?

    <p>Monitor fetal heart rate continuously</p> Signup and view all the answers

    What is the ideal dilation rate for a first-time mother during labor?

    <p>1 cm/hr</p> Signup and view all the answers

    What is a potential outcome of prolonged labor?

    <p>Increased maternal exhaustion</p> Signup and view all the answers

    In which situation is precipitate birth most likely to occur?

    <p>Labor completed in less than 3 hours</p> Signup and view all the answers

    What is a nursing implication when caring for a woman with precipitate birth?

    <p>Observing for maternal and fetal injury</p> Signup and view all the answers

    What is one method used to diagnose premature rupture of membranes?

    <p>Nitrazine paper test</p> Signup and view all the answers

    What is a primary indication for inducing labor?

    <p>Presence of oligohydramnios</p> Signup and view all the answers

    Which condition is a contraindication for tocolytic therapy?

    <p>Pre-eclampsia</p> Signup and view all the answers

    What complication can arise from prolonged pregnancy?

    <p>Skin peeling in the newborn</p> Signup and view all the answers

    What nursing action should be taken when labor induction is initiated?

    <p>Observe for signs of infection in both mother and fetus</p> Signup and view all the answers

    Which of the following factors is NOT associated with preterm labor?

    <p>Regular prenatal care</p> Signup and view all the answers

    What is the goal of tocolytic therapy?

    <p>Stop uterine contractions</p> Signup and view all the answers

    When should corticosteroids be administered during preterm labor?

    <p>Between 24-34 weeks gestation</p> Signup and view all the answers

    Which of the following signs would best indicate the need for immediate action due to potential preterm labor?

    <p>Constant low back pain</p> Signup and view all the answers

    Which medication is commonly used as a B-Adrenergic agonist in tocolytic therapy?

    <p>Terbutaline</p> Signup and view all the answers

    What is the primary nursing care focus when managing a patient undergoing induction of labor?

    <p>Monitoring for infection and assessing fetal wellbeing</p> Signup and view all the answers

    What are the characteristics of hypertonic labor?

    <p>Associated with elevated uterine rest tone.</p> Signup and view all the answers

    Which medical treatment is indicated for hypotonic labor?

    <p>Amniotomy.</p> Signup and view all the answers

    What nursing care is important when managing ineffective maternal pushing?

    <p>Only push when there is a strong urge.</p> Signup and view all the answers

    What is the most common maternal soft-tissue obstruction during labor?

    <p>Full bladder.</p> Signup and view all the answers

    In the case of an abnormal fetal presentation, what is the preferred delivery method?

    <p>Cesarean section.</p> Signup and view all the answers

    What is one of the main problems associated with prolonged labor?

    <p>Increased energy expenditure.</p> Signup and view all the answers

    What nursing intervention is recommended to address excessive and prolonged stress during labor?

    <p>Promote relaxation and comfort.</p> Signup and view all the answers

    What factor may contribute to dysfunctional labor in multifetal pregnancies?

    <p>Uterine over-distention.</p> Signup and view all the answers

    How should a nurse address excessive pain in a laboring woman?

    <p>Provide comfort measures and emotional support.</p> Signup and view all the answers

    Which labor complication is characterized by weak contractions and occurs during the active phase?

    <p>Hypotonic labor.</p> Signup and view all the answers

    Study Notes

    ### Episiotomy & Lacerations

    • Both are surgical enlargements of the vaginal opening during birth
    • Episiotomy is a planned incision with a clean edge.
    • Laceration is an uncontrolled tear with a jagged wound edge.
    • Both are treated with similar interventions:
      • Cold packs for 12 hours
      • Heat packs or sitz baths after 12-24 hours
      • Mild oral analgesics

    Classification of Episiotomy & Lacerations

    • Classified by the amount of tissue involvement.
    • First degree: Superficial, only vaginal mucosa.
    • Second degree: First degree with deeper tissues of the perineum.
    • Third degree: Second degree including the anal sphincter.
    • Fourth degree: Extends through the anal sphincter into the rectal mucosa.

    Forceps and Vacuum Extraction

    • Used as tools to provide traction and rotation to the fetal head during birth.
    • The fetus must be fully dilated and the membranes must be ruptured.
    • Fetal head must be engaged at +2 station.

    Forceps Extraction

    • Consists of two curved metal instruments fit around fetal head.
    • Several styles available for different presentations.

    Vacuum Extraction

    • Uses a cup to provide traction to the fetal head.
    • Used only for fetal occiput presentation.
    • Use has increased since 2001.

    Indications for Forceps or Vacuum Extraction

    • Maternal: Exhausted or unable to push, cardiac or pulmonary disorders.
    • Fetal: Evidence of increased risk.
    • Contraindications: Cesarean birth is preferable.

    Risks of Forceps or Vacuum Extraction

    • Maternal: Lacerations and hematoma of the vagina.
    • Infant: Ecchymosis, facial/scalp lacerations, cephalohematoma, intracranial hemorrhage.
    • Vacuum creates edema, called chignon, at the application area.

    Nursing Implications (Forceps or Vacuum Extraction)

    • Maternal: Place sterile instruments, apply cold packs, observe for vaginal lacerations or hematoma.
    • Infant: Examine the infant's head, watch for facial asymmetry, observe scalp chgnon.

    Cesarean Birth

    • Surgical procedure performed for various indications, including abnormal labor, fetal compromise, maternal conditions.
    • Contraindications: Fetal death, too immature to survive, maternal coagulation defects, convenience.

    Risks of Cesarean Birth

    • Maternal: Anesthesia-related complications, respiratory complications, hemorrhage, blood clots, urinary tract injury.
    • Infant: Preterm birth, respiratory problems, injury.

    Preoperative Nursing Considerations

    • Obtain consent, order lab work, history screening.
    • Assess maternal & fetal vital signs.
    • Provide preoperative teaching.
    • Place mom supine with wedge, regional anesthesia, prophylactic antibiotics, indwelling catheter.

    Postoperative Nursing Considerations

    • Keep family unit together, focus on birth, postoperative assessment.
    • Monitor IV, fundus, and prevent respiratory complications.
    • Facilitate changing positions, pain management, and emotional support.

    Premature Rupture Of Membranes (PROM)

    • Occurs when membranes rupture before onset of labor.
    • Preterm PROM (PPROM): Membranes rupture before 37 weeks.
    • Diagnosis: Nitrazine paper & fern test.
    • Medical management depends on risk of early delivery.
    • Complications: Risk of infection, ultrasound determines gestational age and oligohydramnios.
    • 36 weeks or greater: Induction of labor.

    Nursing Care (PROM)

    • With induction: Observe for signs of infection in mother and fetus, cultures, antibiotics & steroid therapy.
    • Without induction:
      • Report temperature above 100.4F.
      • Avoid sexual intercourse.
      • Limit activity.
      • Note contractions, fetal activity, and infection.
      • Record fetal kick counts daily.

    ### Preterm Labor

    • Occurs between weeks 20 and 37 of gestation.
    • Associated factors:
      • Immaturity of the newborn
      • Fetal morbidity
      • Major medical & economic impact
      • Prevention or identifying risk is key
      • Underweight, poor nutrition, dehydration.
      • Chronic illness, substance abuse, preeclampsia.
      • Anemia, infections, chronic stress.

    Signs of Impending Preterm Labor

    • Shortened cervix at 20 weeks.
    • Presence of fibronectin between 22-24 weeks.
    • Contractions, feeling fetus “balling up”, menstrual cramps, low back pain, pelvic pressure.
    • Change in vaginal discharge, discomfort in vulva or thighs.

    ### Preterm Assessment Tool

    • Standardizes preterm labor care & assessment.
    • Assessment guidelines: Completed in 2-4 hours including history, physical exam, ultrasound, and fibronectin.
    • Optimal delivery of steroids.

    Tocolytic Therapy

    • Goal: Stop uterine contractions.
    • Magnesium: Continuous IV & therapeutic levels monitored. Monitor respirations, lung sounds, urine output, deep tendon reflexes, & bowel sounds.
    • B-Adrenergic: Terbutaline (Brethine) administered SQ. Increases BP & P, nasal stuffiness, hyperglycemia.
    • Prostaglandin inhibitor: Indomethacin causes reduction in amniotic fluid requiring close fetal monitoring.
    • Calcium channel blocker: Nifedipine (Procardia) is most used, causes vasodilation and flushing.
    • Contraindications: Pre-eclampsia, placenta previa, abruptio placentae, 37+ weeks gestation, chorioamnionitis, fetal death.
    • Antimicrobial therapy

    Speeding Fetal Lung Maturation

    • Corticosteroids indicated between 24-34 weeks gestation.
    • Used together with tocolytics.
    • Betamethasone IM x2 doses 24 hours apart.
    • Activity restrictions are moderate.

    Nursing Care (Preterm Labor)

    • Recognize signs of preterm labor.
    • Position side lying, assess VS, I&O, pulmonary edema.
    • Teach appropriate activity and restrictions, make home arrangements.
    • Monitor FHR after delivery and prepare for NICU admission.
    • Provide emotional support to parents.

    Prolonged Pregnancy

    • Lasts between 41 weeks and 41 weeks + 6 days.
    • Risks: Aging placenta, fetal weight loss, meconium, low blood glucose, poor fetal tolerance of labor, macrosomia.

    Medical Management (Prolonged Pregnancy)

    • Evaluate if truly prolonged.
    • Ultrasound clarifies gestational age.
    • Fetal monitoring after 41 weeks.
    • Induction with cervical ripening and oxytocin IV.

    Nursing Care (Prolonged Pregnancy)

    • Observe fetus for poor placental blood flow.
    • After birth, monitor newborn for respiratory distress and hypoglycemia.

    Induction/Augmentation of Labor

    • Induction: Initiating labor before it begins naturally.
    • Augmentation: Stimulation of labor that has begun naturally.

    Induction or Augmentation of Labor

    • Fetal maturity after 39 weeks gestation is preferred.
    • Bishop score of 6 or above indicates a ripened cervix.

    Indications for Induction

    • Continued pregnancy is hazardous for mother or fetus.
    • Gestational hypertension, spontaneous rupture of membranes, chorioamnionitis, maternal medical conditions, fetal problems, placental insufficiency, fetal death.

    Contraindications to Induction

    • Placenta previa, umbilical cord prolapsed, abnormal fetal presentation, high fetal station, active herpes infection, abnormal pelvic size or shape, previous classic cesarean incision.

    Methods to Stimulate Labor

    • Non-pharmacologic: Walking, sitting, squatting, kneeling, nipple stimulation.
    • Pharmacological: Cervical ripening, prostaglandin E2 & E1.
    • Mechanical: Stripping membranes, hydroscopic dilators, transcervical balloon dilators.

    Artificial Rupture of Membranes

    • Amniotomy using disposable plastic hook (Amnihook or AROM finger cot).

    Amniotomy

    • Purpose: Stimulates prostaglandin secretion, stimulating labor.
    • Prior to Procedure: Confirmation of vertex presentation and fetal station.
    • Nursing Implications: Monitor fetal heart rate, observe amniotic fluid, monitor maternal temperature, promote comfort.

    Complications of Amniotomy

    • Prolapse of umbilical cord, infection, abruptio placentae.

    Augmentation of Labor

    • Oxytocin (Pitocin) Induction: Most common method, requires continuous fetal monitoring.
    • Complications: Hypertonic uterine activity, uterine rupture, maternal water intoxication.

    Nursing Implications (Oxytocin)

    • Monitor for non-reassuring fetal heart rate patterns, maternal vital sign changes, and uterine activity.
    • Response: Notify healthcare provider, reposition to left lateral side, decrease or stop oxytocin, give supplemental oxygen, IV bolus of IV fluids, prepare terbutaline, assess uterine contractions & FHR.

    Amnioinfusion

    • Warmed saline or lactated Ringer's solution infused into the uterus after membranes have ruptured.
    • Indications:
      • Oligohydramnios.
      • Umbilical cord compression.
      • Reducing variable decelerations in FHR.
      • Diluting meconium-stained amniotic fluid.
    • Nursing Implications: Continuous monitoring of FHR and uterine activity, document fluid expelled from the vagina.

    Version

    • Method of changing fetal presentation.
    • External: More common, performed after 37 weeks.
    • Internal: Emergency procedure used during vaginal delivery of twins.
    • Successful version reduces the likelihood of cesarean delivery.

    Risks and Contraindications of Version

    • Few maternal or fetal risks.
    • Contraindicated if vaginal birth is not recommended:
      • Pelvic disproportion.
      • Abnormal uterine or pelvic size or shape.
      • Abnormal placental placement.
      • Previous cesarean with vertical uterine incision.
      • Active herpes infection.
      • Inadequate amniotic fluid, poor placental function, multifetal gestation, malfunctioning placenta.

    Technique of Version

    • External:
      • After 37 weeks gestation (before onset of labor).
      • Determine fetal condition, administer tocolytic drugs.
      • Continuous fetal monitoring, RhoGAM administered if mother is Rh-negative.
    • Internal: - Emergency procedure. - Used during vaginal delivery of twins. - Used to change fetal position of second twin.

    Nursing Implications (Version)

    • Baseline VS, fetal monitor strip, observe mother & fetus for 1-2 hours.
    • Observe & report vaginal leaking of amniotic fluid, monitor for uterine contractions.
    • Review signs of labor.

    Problems With Powers

    • Hypertonic Labor:
      • Characterized by strong, frequent, and uncoordinated contractions in the latent phase.
      • Medical Treatment: Tocolytic drugs.
      • Nursing Care: Accept frustration, offer comfort measures, position changes.
    • Hypotonic Labor:
      • Characterized by weak contractions during the active phase.
      • Medical Treatment: Amniotomy, augmentation, IV or oral fluids.
      • Nursing Care: Allow expression of frustration, provide care related to obstetric procedures, encourage position changes.
    • Ineffective Maternal Pushing:
      • Can result from misunderstanding techniques, fear, exhaustion, or pain blocks.
      • Nursing Care: Focus on coaching, tell her when the peak of contraction occurs, explain sensations of tearing are normal, promote relaxation, encourage position changes, increase hydration.

    Problems With The Passenger

    • Abnormal Fetal Presentation:
      • Breech: Usually delivered via cesarean section. External version may be used.
      • Abnormal rotation position: Persistent occiput posterior, may result in longer, intense labor, and may require forceps.
      • Nursing Care: Encourage positions that favor fetal rotation and descent, observe mother and fetus for birth trauma.
    • Multifetal Pregnancy:
      • Uterine over-distention & abnormal presentations.
      • Difficult labor often leads to cesarean.
    • Bony Pelvis:
      • Small or abnormally shaped pelvis may hinder labor.
    • Maternal Soft-Tissue Obstructions:
      • Full bladder: Encourage frequent voiding. Catheterization may be needed.
      • Fibroids, cervical scar tissue.

    Problems With Psyche

    • Common Factors: Excessive pain, absence of support person, prolonged immobility, inability to practice cultural traditions.
    • Excessive & Prolonged Stress: Releases hormones that reduce uterine contractility, increases glucose use, increases tension of pelvic muscles, increases perception of pain.
    • Nursing Care: Promote relaxation and comfort, help conserve energy.

    Prolonged Labor

    • Average rate of cervical dilation: 1.2 cm/hr for first-time moms, 1.5 cm/hr for those who have had a baby before.
    • Average rate of decent: 1 cm/hr for first-time moms, 2 cm/hr for those who have had a baby before.
    • Problem with any of the factors of labor.

    Friedman's Curve -

    • A tool to graph labor progress
    • Can help identify prolonged labor

    Results Of Prolonged Labor

    • Maternal & newborn infection, maternal exhaustion, postpartum hemorrhage, anxiety, fear.

    Nursing Care (Prolonged Labor)

    • Maternal: Conserve energy, provide emotional support, assess for infection.
    • Fetal: Watch for signs of infection.

    Precipitate Birth

    • Labor completed in less than 3 hours.
    • Maternal Response: Labor begins abruptly, intensifies quickly.
    • Fetal Response: Oxygenation compromise, birth injuries, intracranial hemorrhage, nerve damage.
    • Nursing Care: Support and reassurance, observe for maternal and fetal injury, assess for mother and infant injury.

    Complications of Labor & Delivery

    • Hypertonic Labor: Strong, frequent, uncoordinated contractions, tense uterine rest tone.
      • Treatment: Tocolytics
      • Nursing: Comfort measures, position changes
    • Hypotonic Labor: Weak contractions during the active phase.
      • Treatment: Amniotomy, augmentation, fluids.
      • Nursing: Support, comfort measures, position changes
    • Ineffective Maternal Pushing: Mother may not be able to push effectively due to fear, pain, misunderstandings, or exhaustion.
      • Nursing: Provide coaching and support, ensure appropriate pushing techniques.
    • Abnormal Fetal Presentation: Breech or abnormal rotation position.
      • Nursing: Encourage fetal rotation and descent, assess for birth trauma.
    • Multifetal Pregnancy: Uterine overdistention, abnormal presentations.
      • Nursing: Monitor for complications and support the mother.
    • Bony Pelvis: Small or abnormally shaped pelvis.
      • Nursing: Monitor for labor progress, be prepared for complications.
    • Maternal Soft-Tissue Obstructions: Full bladder, fibroids, cervical scar tissue.
      • Nursing: Encourage frequent voiding, monitor for labor progress.
    • Excessive & Prolonged Stress: Psychological stress can impede labor progress.
    • Nursing: Provide support and relaxation techniques.
    • Prolonged Labor: Labor exceeding expected timelines.
      • Nursing: Monitor progress, assess for complications.
    • Precipitate Birth: Rapid labor and delivery.
      • Nursing: Provide support, monitor for complications and infant distress.
    • Premature Rupture of Membranes: Membranes rupture before onset of labor.
      • Nursing: Monitor fetal heart rate, observe for infection.

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