High-Risk Pregnancy and Labor Complications

Unit 2: High-Risk Pregnancy and Complications During Labor

• Five main components of labor and birth processes contribute to potential complications.

Causes of Complications

• Dysfunctional labor is most common
• Alterations in the pelvic structure
• Fetal factors: malpresentation, anomalies, excessive size, or multiple fetuses.
• Maternal position during labor and birth
• Psychological response of the mother

Risk Factors

• Body composition: overweight or short stature
• Uterine abnormalities like unicornuate and bicornuate uterus
• Fetal malpresentation and malposition
• Cephalopelvic disproportion
• Overstimulation with oxytocin without a ripe cervix
• Maternal conditions dehydration, electrolyte imbalance, fatigue, fear)
• Inappropriate timing of anesthetic

Interventions

• Monitor maternal well-being with vital signs and pain assessment
• Monitor fetal well-being
• External Cephalic Version is used when there's a problem with fetal position or presentation.
• Trial of Labor
• Cervical Ripening
• Induction or Augmentation of Oxytocin
• Amniotomy is the artificial rupturing of amniotic membrane to hasten delivery after engagement.
• Operative procedures vacuum delivery or forcep-assisted birth

Bishop Scoring

• Evaluates cervical readiness for labor
• Assesses cervical dilatation, effacement, station, consistency, and position
• Score ranges from 0-3 for each factor

Complications Related to Labor Power (Force)

• Dystocia: Long, difficult, or abnormal labor
• Dystocia is suspected when there is alteration in uterine contractions, cervical dilatation rate, or fetal descent
• Inertia sluggishness of contractions or diminished labor force

Classifications of Inertia

• Primary dysfunction occurs at onset
• Secondary dysfunction occurs later

Causes of Inertia

• Primigravida status
• Pelvic bone contraction
• Cephalopelvic disproportion
• Occiput posterior malposition
• Failure of uterine muscle contraction
• Overdistension of the uterus
• Full bladder or bowel
• Maternal exhaustion
• Inappropriate use of analgesia

Ineffective Uterine Force

• Uterine contraction overview adenosine triphosphate (ATP), electrolytes, contractile proteins, epinephrine, norepinephrine, oxytocin, estrogen, progesterone, and prostaglandins
• Hypotonic contractions contractions are infrequent, typically not more than 2-3 in a 10-minute period.
• Uterine tone remains below 10mmHg, and contraction strength doesn't exceed 25mmHg.
• Hypotonic contractions tends to occur during the active labor phase after analgesia.
• Labor duration increases as more contractions are needed.
• Hypertonic contractions are marked by resting tone exceeding 15mmHg, potentially reaching 35-40mmHg
• Contractions tend to occur frequently
• Occurs when myometrium fibers fail to repolarize or relax after contraction
• Insufficient relaxation may lead to fetal anoxia by restricting uterine artery filling

Risk Factors for Hypertonic Uterine Contractions

• Elevated maternal catecholamine release (epinephrine, norepinephrine)
• Maternal anxiety primiparous labor, fear of loss of control, sexual abuse history, lack of support, cultural differences)
• Fetal occiput-posterior malposition
• Uncoordinated contractions more than one pacemaker initiates or receptor points act independently.
• Erratically occurring contractions produce abnormal fetal monitor patterns.
• Uncoordinated contractions can cause hypertonic but mild uterus

Interventions for Complications

• If Bishop score is over 8, cervix is suitable for induction
• Uterine exhaustion can lead to ineffective postpartum contractions and increase postpartum hemorrhage risks
• Hypertonic interventions adequate fluid, pain relief (morphine sulphate), changing linen, darkening lights, and decreasing noise
• Ineffective interventions consider Cesarean birth, amniotomy or oxytocin infusion

Lengths of Phases in Normal Labor

• Latent phase averages 8.6 hours (up to 20) for nulliparas, 5.3 hours (up to 14) for multiparas
• Active phase averages 4.9 hours (1.2cm/hour dilatation rate, up to 12) for nulliparas, 2.5 hours (1.5cm/hour dilatation rate, up to 6) for multiparas
• Second stage averages 1 hour (up to 2 without epidural, 3 with) for nulliparas, 0.5 hours (up to 1 without epidural, 2 with) for multiparas.
• Placental stage averages 30 minutes for both

Dysfunctional Labor Patterns

• Prolonged Latent Phase nullipara > 20 hours, multipara > 14 hours
• Protracted Active Phase nullipara < 1.2cm/hr dilatation, multipara < 1.5cm/hr dilatation
• Secondary Arrest in Dilatation > 2 hours, no dilatation
• Protracted Descent nullipara <1 cm/hour during 2nd stage, multipara <2cm/hour during 2nd stage
• Arrest of Descent nullipara >1 hour during 2nd stage, multipara >½ hour during 2nd stage.
• Failure of Descent No change during 2nd stage

Dysfunctional Labor at 1st Stage

• Prolonged Latent Phase longer than 20 hours (nullipara) or 13 hours (multipara) Contractions become ineffective
• Causes unripe cervix, excessive early analgesic use

Dysfunctional Labor at Active Phase

• Phase prolongs if dilatation rate is under 1.2 cm/hr (nullipara) or 1.5 cm/hr (multipara)
• Active phase lasts over 12 hours (primigravida) or 6 hours (multigravida)
• Causes cephalopelvic disproportion (CPD), fetal malposition, ineffective myometrial activity.
• Interventions cesarean birth or oxytocin augmentation

Prolonged Deceleration Phase

• Lasts beyond 3 hrs (nullipara) or 1 hr (multipara)
• Results from abnormal fetal head position
• Requires Cesarean birth

Secondary Arrest in Dilatation

• No progress in cervical dilatation for over 2 hrs.
• May need C-section

Dysfunctional Labor at 2nd Stage

• Suspect prolonged descent if 2nd stage exceeds 3 hours (multiparas)
• Contractions have proper duration, effacement and dilatation, but become infrequent

Interventions at 2nd Stage

• Ultrasound to eliminate CPD and bad fetal position
• Place patient in semi-Fowler, squatting, kneeling, to boost pushing

Arrest of Descent and Interventions

• If no descent in 1 hr (multipara) and 2 hrs (nullipara)
• Occurs when descent doesn't start or movement past station 0 doesn't occur
• Usually result of CPD
• Requires CS, oxytocin (if no contraindications)

Pathologic Retraction Ring

• Also called Bandl's Ring
• Indicates severe dysfunctional labor
• Grips fetus, prevents advancement, impacts placenta
• Hard band across uterus at the junction of upper and lower uterine segments and interferes with fetal descent.

Precipitate Labor

• Rapid and strong contractions completed in a few hours (under 3). Precipitate dilatation occurs at a rate of 5 cm/hour or higher (primipara), 10 cm/hour or higher (multipara)

Causes and Complications of Precipitate Labor

• Causes grand multiparity and oxytocin induction or amniotomy
• Premature separation of the placenta, hemorrhage, subdural hemorrhage
• Interventions caution multiparous women, prepare the labor room, administer a Tocolytic

Indications for Labor Induction and Augmentation

• Includes insufficient contractions, dystocia and intrauterine growth restriction

Contraindications for Labor Induction and Augmentation

• Include CPD, fetal malposition, prolapsed cord, non-reassuring fetal heart rate and placenta previa

Complications and Cautions for Labor Induction

• Uterine rupture risk and decreased fetal blood supply and premature separation of the placenta risk means it should be used cautiously in multiple gestation, hydramnios or older mothers

Salivary Estriol and Cervical Length

• Salivary Estriol Estrogen detected in plasma at 9 weeks and increases before preterm
• Testing happens every 2 weeks for around 10 weeks
• Cervical Length 35mm at 24-28 weeks more prone for preterm birth

Preterm Labor Symptoms

• Uterine movement may occur every 10 and persist for an hour or longer. A vaginal discharge may change
• Interventions are to inform about indications , lifestyle modifications, and tocolytic medicine usage

Post Term Birth

• Pregnancy lasts > 42 weeks after LMP
• Post term newborn features: alert , much hair and skin peeling.

Fetal & Maternal Complications

In addition to umbilical cord complications which will lead from compression, there are placental complications and anoxia

Uterine Rupture

Also comes with various obstetric injuries and is caused by an intense and sustained uterine contraction

Amniotic fluid embolism

From debris particles which creates problems of respiratory distress and circulatory issues

Prolapse of Umbilical Cord

Occurs if the cord slides ahead of your head.

Amnioinfusion

Helped to reduce risk that baby needs more support.

Cord Prolapse Interventions

Is to notify people nearby and utilize 2 fingers in the vagina

Gestation Multiple Signs

Abortion and malformation.

Labor and birth complications

Can be identified via examination, can result in anoxia. Ensure that the staff has access to the umbilical cord by using two permanent rather than two metal clamps

Fetal Indications

Those can be indications of a fetal malpresentation and arrest of rotation.

• Prolonged Labor Complications Include uterine dysfucntion and a higher likelihood of the need for forcepts or a C- Section. Malposition Is related to the back and fetal issues Amniotomy Helps to reduce contractions. The face presentations might have a rare brow. A head is not commonly seen.

Positioned Fetus

• The doctor, the nurse will try, encourage the fetus into a correct position, use certain medicines and try to avoid a section.

Placental Positioning

Where the child is can affect where it is retained- always observe where it's located and retained

Power Of The Main Section

Is identified as the hard band which can cut off portions of your body and is most often found amongst gestations.