3. COMPLICATIONS DURING LABOR AND BIRTH

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Questions and Answers

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?

Gestational hypertension Signup and view all the answers

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

Cold packs for the first 12 hours Signup and view all the answers

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

Chronic hypertension Signup and view all the answers

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

Facial asymmetry Signup and view all the answers

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

Administering analgesics Signup and view all the answers

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

Hazardous conditions for mother or fetus Signup and view all the answers

Which of the following is a contraindication to labor induction?

Placenta previa Signup and view all the answers

What complication can arise from an amniotomy?

Placental abruption Signup and view all the answers

What condition is NOT an indication for labor induction?

Maternal obesity Signup and view all the answers

Following an amniotomy, what nursing implication is essential?

Observe amniotic fluid's color and odor Signup and view all the answers

Which method is commonly used to stimulate contractions pharmacologically?

Misoprostol (Cytotec) Signup and view all the answers

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

Induce or augment contractions Signup and view all the answers

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

Notify the healthcare provider and reposition the patient Signup and view all the answers

What is a potential complication of using amnioinfusion?

Variable decelerations in fetal heart rate Signup and view all the answers

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

Monitor fetal heart rate continuously Signup and view all the answers

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

1 cm/hr Signup and view all the answers

What is a potential outcome of prolonged labor?

Increased maternal exhaustion Signup and view all the answers

In which situation is precipitate birth most likely to occur?

Labor completed in less than 3 hours Signup and view all the answers

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

Observing for maternal and fetal injury Signup and view all the answers

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

Nitrazine paper test Signup and view all the answers

What is a primary indication for inducing labor?

Presence of oligohydramnios Signup and view all the answers

Which condition is a contraindication for tocolytic therapy?

Pre-eclampsia Signup and view all the answers

What complication can arise from prolonged pregnancy?

Skin peeling in the newborn Signup and view all the answers

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

Observe for signs of infection in both mother and fetus Signup and view all the answers

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

Regular prenatal care Signup and view all the answers

What is the goal of tocolytic therapy?

Stop uterine contractions Signup and view all the answers

When should corticosteroids be administered during preterm labor?

Between 24-34 weeks gestation Signup and view all the answers

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

Constant low back pain Signup and view all the answers

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

Terbutaline Signup and view all the answers

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

Monitoring for infection and assessing fetal wellbeing Signup and view all the answers

What are the characteristics of hypertonic labor?

Associated with elevated uterine rest tone. Signup and view all the answers

Which medical treatment is indicated for hypotonic labor?

Amniotomy. Signup and view all the answers

What nursing care is important when managing ineffective maternal pushing?

Only push when there is a strong urge. Signup and view all the answers

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

Full bladder. Signup and view all the answers

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

Cesarean section. Signup and view all the answers

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

Increased energy expenditure. Signup and view all the answers

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

Promote relaxation and comfort. Signup and view all the answers

What factor may contribute to dysfunctional labor in multifetal pregnancies?

Uterine over-distention. Signup and view all the answers

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

Provide comfort measures and emotional support. Signup and view all the answers

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

Hypotonic labor. 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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